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Presented  hij 
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COLLEGE  OF  OSTEOPATHIC  PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


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LOS  ANGELES,  CALIFORNIA 


INJURIES  6P  DISEASES 

OF  THE 

BONES  AND  JOINTS 


INJURIES  6?  DISEASES 
OF  THE  BONES  AND  JOINTS 

THEIR  DIFFERENTIAL  DIAGNOSIS  BY  MEANS  OF  THE  ROENTGEN  RAYS 


BY 

FREDERICK  H.  BAETJER,  M.D. 

Associate  Professor  of  Roentgenology,  Johns  Hopkins  University;  Roentgenologist, 
Johns  Hopkins  Hospital 

AND 

CHARLES  A.  WATERS,  M.D. 

Instructor  in  Roentgenology,  Johns  Hopkins  University;  Assistant 
Roentgenologist,  Johns  Hopkins  Hospital 


ILLUSTRATED  WITH   332  ROENTGENOGRAMS 
AND  ONE  LINE  DRAWING 


NEW  YORK 

PAUL  B.  HOEBER 

192 1 


Copyright,  192  i 
By  PAUL  B.  HOEBER 


All  Rights  Reserved 


Published,  March  1921 


Printed  in  the  United  States  of  America 


To 

William  Stewart  Halsted 

Dear  Dr.  Halsted, 

Tour  l^nd  consent  to  accept  the  dedication  of  this 
hoo\  has  brought  to  a  happy  conclusion  our  labors  of 
the  past  year. 

Tour  sympathy  and  encouragement  have  been  a 
constant  stimulus  in  the  study  of  the  many  problems 
which  have  confronted  us. 

We  offer  to  you  this,  our  first  boo\,  as  a  to\en 
of  the  esteem  and  gratitude  in  which  we  hold  you  as 
one  who  has  ever  represented,  not  only  to  us  but  to 
the  profession  at  large,  the  best  ideals  in  surgery. 

Ver}'  sincerely  yours, 

F.  H.  Baetjer 
C.  A.  Waters 

February  28,  1921. 


PREFACE 

THE  TECHNICAL  side  of  roentgenology  has  been  so 
ably  described  by  various  authors  that  mention  of  it 
is  mere  repetition,  therefore,  we  have  in  this  book, 
confined  ourselves  to  the  study  of  the  finished  product — the 
plate. 

Our  object  then,  is  to  show  that  roentgenology  is  not  a 
picture  process,  but  a  medical  procedure  based  upon  careful 
analysis  and  logical  deductions  from  the  shadows  observed 
upon  a  plate  and  the  translation  of  these  shadows  into 
pathological  terms. 

The  constituent  parts  of  the  normal  bones  and  their 
functions  have  been  discussed;  and  with  these  as  a  basis,  the 
lesions  have  been  studied  and  correlated  with  the  gross 
pathological   findings  of  the   operating  and   autopsy   rooms. 

Age  and  sex  play  such  an  important  role  in  the  production, 
character  and  situation  of  the  lesion  that  we  have  linked  them 
up  with  the  .\-ray  plate  in  arriving  at  a  diagnostic  conckision. 

Inasmuch  as  the  pathological  findings  and  classifications 
in  certain  types  of  bone  and  joint  lesions  are  not  yet  thoroughly 
established,  we  may  state  that  in  the  same  way  our  interpreta- 
tions of  the  -V-ray  shadows  of  these  lesions  also  may  be  subject 
to  revision  in  the  light  of  further  pathological  investigations. 

No  attempt  has  been  made  to  give  a  bibliography,  as  this 
book  is  the  result  of  our  observations  in  theclinicof  the  Johns 
Hopkins  Hospital.  In  this  connection  we  wish  to  express  our 
appreciation  for  the  assistance  given  us  by  the  x-ray  Staff  of 
the  Johns  Hopkins  Hospital. 

vii 


22837 


VIII 


PREFACE 


In  conclusion  our  thanks  are  also  due  to  Mr.  Paul  B. 
Hoeber  and  his  editorial  staff  for  their  painstaking  care  and 
efficient  cooperation  in  the  preparation  of  this  volume. 

F.  H.  B. 
C.  A.  W. 

Februan,'  28,  1921. 


CONTENTS 

Chapter  Page 

I    Introduction ^ 

II.  Normal  Bones 13 

The  Periosteum,  The  Cortex,  The  Medullary  Canal,  The  Nutrient 
Foramen,  Cartilage,  Joints,  Growth,  Joint  Lesions,  Eflect  of  Sex. 

III.  Epiphyses 33 

Scapula,  Clavicle,  Humerus,  Radius,  Olecranon,  Carpal  Bones,  Pha- 
langes, Pubis  and  Ischium,  Femur,  Patella,  Tibia  and  Fibula,  Vertebrae. 

IV.  Fractures  of  the  Upper  Extremities 47 

Elements  Affecting  Fractures— Muscular  Tension,  Age  and  Sex,  Occu- 
pation, Condition  of  Soft  Tissues,  Bone  Atrophy,  Formation  of  Callus. 
Fractures  from  Pathological  Causes,  Fractures  Classified  According 
to  Age— The  Skull,  Facial  Bones,  Mandible,  Clavicle,  Scapula, 
Humerus,  Forearm,  Wrist,  Hand,  Ribs,  Sternum,  Pelvis. 

V.  Fractures  of  the  Lower  Extremities 99 

Femur,  Patella,  Tibia  and  Fibula,  Bones  of  the  Foot,  Astragalus, 
Os  Calcis,  Scaphoid,  Cuboid  and  Cuneiforms,  Metatarsal  Bones, 
Phalanges,  Sesamoids,  Bone  Splints. 

VI.  Congenital  Dislocations 133 

Congenital  Dislocations  of  tiie  Hip,  Dislocations  of  the  Shoulder 
Joint,  Abnormalities  in  the  Development  of  Epiphyses. 

VII.  Acquired  Dislocations 145 

Shoulder,  Elbow,  Ulna  and  Radius,  Wrist,  Hand,  Pelvic  Bones,  Hip, 
Patella,  Knee,  Tibia,  Fibuhu 

VIII.  Bone  Infections 1^9 

Osteomyelitis — ^Tuberculosis,  Lues.  Typhoid,  Actinomycosis,  Raynaud's 
Disease,  Leprosy,  Coccidoidal  Granuloma,  Mineral  Poisoning,  Special 
Infections. 

IX.  Joint  Lesions  in  Children 183 

Rickets,  Congenital  Lues,  Scurvy,  Tuberculosis,  Acute  Epiphysitis — 
Non-tuberculous,  Perthes's  Disease  or  Juvenile  Deforming  Osteochond- 
ritis. 

X.  Joint  Lesions  in  Adults 205 

Changes  Indicating  an  Arthritic  Condition,  Acute  Polyarticular 
Rheumatism,  Chronic  Arthritis — ^Tuberculosis,  Caries  Sicca,  Luetic 
Arthritis,  Atrophic,  Hypertrophic  Arthritis.  Gonorrheal  Arthritis, 
Arthritic  Changes  due  to  Age,  Arthritis  in  the  Spine,  Villous 
Arthritis,  Non-arthritic  Joint  Lesions — Gout,  Charcot  Joint,  Syringo- 
myelia. Hemophilia,  Arthritic  Changes  in  Ligaments. 

IX 


X  CONTENTS 

Chapter  Page 

XI.  Bone  Tumors 241 

-Method  of  Analyzing  Bone  Tumors,  Carcinoma,  Hypernephroma, 
Round-cell  Sarcoma,  Spindle-cell  Sarcoma,  Periosteal  and  Osteo- 
sarcoma, Myeloma,  Giant-cell  Sarcoma,  Enchondroma  or  Osteochon- 
droma, Cyst,  Osteoma,  Fibroma,  Myxoma,  Hemangiomata,  Ossifying 
Hematoma,    Osteitis    Fibrosa  Cystica,  Brain  Tumors. 

XII.  The  Spine 289 

Conformation,  Divisions,  Classification  of  Lesions,  Diagnostic  Aids, 
Arthritis,  Infectious  Arthritis,  Acute  Spondylitis  Deformans,  Charcot 
Spine  and  Syringomyelia,  Tumors,  Application  of  Classification  Aids, 
Functional  Conditions. 

XIII.  Abnormalities 3^1 

Extra  Ribs,  Non-union — Rudimentary  Vertebrae,  Abnormalities  in 
the  Lumbosacral  Region,  Clavicle,  Scapula,  Shoulder,  Forearm, 
Hand,  Femur,  Tibia  and  Fibula,  Ankle  and  Foot. 

XIV.  Dystrophies 323 

Acromegaly,  Osteomalacia,  Chondrodystrophies,  Pulmonary  Osteo- 
arthropathy, Osteogenesis  Imperfecta,  Dyschondroplasia. 


LIST  OF  ILLUSTRATIONS 

Figure  Page 

1.  Section  of  normal  radius  and  ulna  with  periosteum  invisible.  ...  14 

2.  Deposition  of  calcium  salts  in  the  periosteum  of  tiie  tibia 15 

3.  Bony  cortex  of  the  tibia 16 

4.  Finely  reticulated  bony  structure  at  the  end  of  the  bones 17 

5.  Medullary  canal  in  the  long  bones 18 

6.  Joint  cartilage IQ 

7.  Cartilage  present  in  costal  cartilage IQ 

8.  Tibia  and  fibula  showing  cortex,  medullary  canal,  and  cancellous 

bone 20 

9.  Flat  bone  with  grooves  for  blood  vessels  visible 20 

10.  Carpal  bone 20 

1 1.  Normal  joint  space  filled  with  cartilage 22 

12.  Destruction  of  cartilage  in  joint  space 22 

13.  Abnormally  wide  joint  space  at  the  knee  in  early  childhood 23 

14.  Wide  epiphyseal  lines  in  the  wrist  of  a  child  of  seven •  •  23 

15.  Narrowing  of  epiphyseal  line  of  the  first  metacarpal  in  a  child 

of  eleven 24 

16.  Head  of  humerus  of  a  new-born  child 25 

17.  Atrophy  in  shoulder  joint  of  a  man  of  fifty 26 

18.  Position  of  the  sacrum  in  the  female  pelvis 28 

19.  Position  of  the  sacrum  in  the  male  pelvis 29 

20.  Ossification  of  epiphyseal  centers  in  a  child  ot  eigiiteen  months.  .  34 

21.  Ossification  of  epiphyseal  centers  in  a  child  of  three  years 34 

2:1.  Delayed  ossification  of  carpal  bones  in  a  child  of  ten  years 34 

23.  Ossification  of  the  epiphysis  of  the  acromion  in  a  child  of  fifteen 

years 34 

24.  Ossification  of  the  head  of  the  humerus  in  a  child  of  four  years.  35 

25.  Epiphysis  at  the  elbow  joint  in  the  fourteenth  year 3" 

26.  Lower  epiphysis  of  the  radius 37 

27.  Epiphysis  of  the  olecranon  at  the  fifteenth  year }P 

28.  Centers  of  ossification  of  the  carpal  bones  at  four  years 38 

29.  Centers  of  ossification  of  the  carpal  bones  at  seven  years 38 

30.  Centers  of  ossification  of  the  carpal  bones  at  eleven  years 38 

31.  Pubis  and  ischium  at  five  years 39 

32.  Epiphysis  of  the  greater  trochanter  at  nine  years 4^^ 

33.  Epiphysis  of  the  lower  end  of  the  femur  in  child  under  six  months  4 1 

34.  Epiphyseal  center  of  the  patella  at  four  years 42 

35.  Well-developed  head  of  the  tibia  at  eight  years 42 

36.  Epiphyseal  centers  of  the  ankle  joint  present  at  birth 43 

xi 


xii  LIST  OF  ILLUSTRATIONS 

Figure  Page 

37.  Three  centers  of  ossification  in  the  vertebrae 43 

38.  Location  of  the  epiphyses  of  the  hrst  and  other  metacarpals ....  44 

39.  Swelhng  from  fracture  of  the  lower  third  of  the  radius 50 

40.  Old  Colles's  fracture  showing  marked  atrophj- 50 

41.  Callus  formation  six  weeks  after  fracture $2 

42.  Backward  displacement  of  the  lower  end  of  the  humerus §2 

43.  V-shapcd  skull  fracture  with  depression  in  the  frontal  region. .  .  ^^ 

44.  Linear  skull  fracture  in  the  occipital  region 56 

45.  Fracture  of  the  malar  bone  with  hemorrhage  into  the  sinus 57 

46.  Fracture  of  the  mandible  followed  by  osteomyelitis 58 

47.  Fracture  of  the  condyle  of  the  mandible  with  displacement 58 

48.  Fracture  of  the  coronoid  process  of  the  mandible 60 

49.  Oblique  fracture  of  the  mandible,  not  complete 60 

50.  Green-stick  fracture  of  the  outer  third  of  the  clavicle  in  a  child..  61 

51.  Fracture  of  the  outer  third  of  the  clavicle  with  slight  displacement  62 
^2.  Fracture  of  the  extreme  tip  of  the  clavicle 63 

53.  Fracture  of  the  body  of  the  scapula 63 

54.  Fracture  at  the  base  of  the  spine  of  the  scapula 64 

55.  Fracture  and  displacement  beneath  the  glenoid  fossa 65 

§6.  Linear  fracture  of  the  coracoid  process 65 

57.  Fracture  of  the  tip  of  the  acromial  process 66 

58.  Epiphyseal  separation  of  the  upper  end  of  the  humerus 66 

59.  Fracture  of  the  surgical  neck  of  the  humerus 6v 

60.  Fracture  of  the  head  of  the  humerus  with  outward  displacement.  .  68 

61.  Fracture  of  tuberosity  and  surgical  neck  of  the  humerus  with 

atrophy 69 

62.  Fracture  of  the  surgical  neck  of  the  humerus 70 

63.  Old  fracture  of  the  greater  tuberosity  of  the  humerus 71 

64.  Epiphyseal  separation  of  the  lower  end  of  the  humerus 72 

65.  Green-stick  fracture  of  the  humerus 72 

66.  Spiral  fracture  of  the  humerus 72 

67.  Attempted  reduction  of  supracondylar  fracture  of  lower  end  of 

the  humerus 73 

68.  Fracture  of  the  external  condyle  of  the  lower  end  of  the  humerus  74 

69.  Fracture  of  the  olecranon  process 75 

70.  Fracture  of  the  olecranon  process 75 

71.  Fracture  of  the  coronoid  process 76 

72.  Fragment  of  the  head  of  the  radius 76 

73.  Fracture  of  the  head  of  the  radius 77 

74.  Fracture  of  the  neck  of  the  radius 77 

75.  Fracture  of  the  upper  third  of  the  ulna — lateral  view 78 

76.  Fracture  of  the  upper  third  of  the  ulna — anteroposterior  view.. .  78 

77.  Old  fracture  of  the  upper  third  of  the  ulna 79 

78.  Green-stick  fracture  of  the  radius  and  ulna 79 

79.  Fracture  and  displacement  of  the  radius  and  ulna 80 


LIST  OF  ILLUSTRATIONS  xiii 

Figure  Page 

80.  Backward  dislocation  of  the  epiphysis  of  the  radius 80 

81.  Epiphyseal  separation  of  the  lower  end  of  the  radius 81 

82.  Fracture  of  both  bones  of  the  forearm  at  site  of  Colles's  fracture  82 

83.  Fracture  of  the  forearm  at  site  of  Colles's  fracture 82 

84.  Colles's  fracture  of  the  forearm  with  marked  displacement 83 

85.  Colles's  fracture  with  anterior  displacement  of  the  lower  fragment  83 

86.  Old  Colles's  fracture  with  backward  displacement 84 

87.  Impacted  Colles's  fracture  without  displacement 84 

88.  Old  Colles's  fracture  with  angulation.     No  displacement 85 

89.  Barton's  fracture 86 

90.  Old  fracture  of  the  styloid  of  the  radius 86 

91.  Fracture  of  the  scaphoid  of  the  wrist  without  displacement 88 

92.  Colles's  fracture  associated  with  the  scaphoid.     No  displacement  88 

93.  Fracture  of  the  first  metacarpal  bone  with  displacement 89 

94.  Oblique  fracture  of  a  metacarpal  bone  without  displacement ....  89 

95.  Fracture  of  the  first  metacarpal  bone  with  angulation 89 

96.  Longitudinal  fracture  of  the  terminal  phalanx  of  the  thumb ....  90 

97.  Crushing  fracture  of  the  terminal  phalanx  with  osteomyelitis.  . .  90 

98.  Base-ball  Finger 90 

99.  Fracture  of  several  ribs  with  slight  displacement 91 

99a.  Fracture  of  the  sternum  showing  lateral  displacement 92 

GO.  Fracture  of  the  upper  third  of  the  femur,  ilium  and  pubis 93 

01.  Fracture  of  ischium  and  pubis 94 

02.  Fracture  of  the  ilium  bj^  a  crushing  injury 95 

03.  Fracture  of  the  acetabulum  with  head  of  femur  in  pelvic  canal..  96 

04.  The  epiphyseal  separation  of  the  head  of  the  femur 100 

05.  Fracture  of  the  neck  of  the  femur  just  behind  the  head loi 

06.  Old  fracture  of  the  mid  portion  of  the  neck  of  the  femur 102 

07.  Intertrochanteric  fracture 103 

08.  Absorption  of  the  neck  of  the  femur  in  old  ununited  fracture.  .  .  .  104 

09.  Healed  fracture  of  the  neck  of  the  femur  without  callus 105 

10.  Intertrochanteric  fracture  with  coxa  vara 106 

1 1.  Position  of  a  fracture  of  the  upper  third  of  the  femur 107 

12.  Green-stick  fracture  of  the  femur 108 

13.  Transverse  fracture  of  the  femur 108 

14.  Epiphyseal  separation  of  the  lower  end  of  the  femur no 

15.  Old  epiphyseal  separation  of  the  lower  end  of  the  femur 1 1 1 

16.  Oblique  fracture  of  the  lower  end  of  the  femur 112 

17.  Lateral  view  of  Fig.  1 16  with  line  of  fracture  visible 113 

18.  Fracture  of  the  patella 114 

19.  Fracture  of  the  patella 114 

20.  Fracture  of  the  tibial  tubercle 114 

21.  Fracture  of  the  tuberosity  of  the  tibia 115 

22.  Fracture  of  the  upper  end  of  the  fibula 1 16 

23.  Fracture  of  the  external  tibial  spine 1 1- 


xiv  LIST  OF  ILLUSTRATIONS 

Figure  Page 

124.  Green-Stick  fracture  of  the  tibia  in  the  first  age  period 118 

125.  Oblique  fracture  of  tiie  tibia  in  the  first  age    period 118 

126.  Spiral  fracture  of  the  tibia  in  the  first  age  period 118 

127.  Comminuted  fracture  of  tibia  and  fibula 118 

128.  Epiphyseal  separation  of  the  lower  end  of  the  tibia 1 19 

129.  Fracture  of  the  lower  end  of  the  tibia 119 

130.  Typical  Pott's  fracture,  anteroposterior  view 120 

131.  Lateral  view  of  a  Pott's  fracture 120 

132.  Clear  triangle  in  the  soft  parts  at  the  normal  ankle  joint 121 

133.  Triangle  obscured  by  swelling  from  injury  or  disease 121 

134.  Fracture  of  the  astragalus 122 

135.  Fracture  of  the  end  of  the  astragalus 122 

136.  Fracture  of  the  os  calcis  due  to  a  crushing  injury 123 

13".  Fracture  of  the  tip  of  the  scaphoid 123 

138.  Old  fracture  of  the  cuboid,  with  callus  formation 124 

139.  Fractures  of  metatarsals  and  phalanges 124 

140.  Fracture  of  the  base  of  the  fifth  metatarsal 125 

141.  Old  fracture  of  the  tibia  with  bone  graft 126 

142.  Bone  transplant  of  the  upper  end  of  the  humerus 128 

143.  Pressure  atrophy  around  the  ends  of  the  bone  graft 128 

144.  Old  fracture  of  the  humerus  with  bone  graft 129 

145.  Metal  plate  acting  as  an  irritant 129 

146.  Tibia  after  a  bone  graft  has  been  removed 130 

14-^.  Straight  sides  of  the  pelvis  before  walking 134 

148.  Beginning  concavity  of  the  sides  of  the  pelvis 135 

149.  Congenital  dislocation  of  the  hip  with  shallow  acetabulum 135 

150.  Destruction  of  the  head  of  the  femur  with  dislocation 136 

151.  Bony  ankylosis  seen  in  non-tuberculous  infection 137 

152.  Undeveloped  femur  in  congenital  dislocation 138 

153.  Congenital  dislocation  of  both  hips  with  shallow  acetabula 138 

154.  Partial  subluxation  of  the  ankle  joint  from  injury 139 

ijj.  Club  foot 139 

156.  Club  hands 139 

15-".  Abnormality  of  the  femur  due  to  anterior  poliomyelitis 140 

158.  Subcoracoid  dislocation  of  the  humerus 146 

159.  Subglenoid  dislocation  with  unusual  position  of  the  humerus. . . .  147 

160.  Subglenoid  dislocation  with  usual  position  of  the  humerus 147 

161.  Subglenoid  dislocation  of  the  humerus  associated  with  fracture. .  148 

162.  Dislocation  of  both  bones  of  the  forearm  backward 149 

163.  Another  view  of  Fig.  162  showing  lateral  displacement 149 

164.  Dislocation  of  the  elbow 149 

165.  Lateral  view  of  Fig.  164 149 

166.  Dislocation  of  the  elbow  reduced 150 

167.  Dislocation  of  the  wrist  joint 150 

168.  Anterior  dislocation  with  rotation  of  the  semilunar 150 


LIST  OF  ILLUSTRATIONS  xv 

Figure  Page 

169.  Backward  dislocation  of  the  thumb  plialanx 151 

170.  Backward  dislocation  of  the  hip 152 

171.  Obturator  dislocation  of  the  hip 153 

172.  Lateral  dislocation  of  the  patella 154 

173.  Subluxation  of  the  tibia 154 

174.  Posterior  dislocation  of  the  foot 155 

175.  Dislocation  of  the  hrst  metatarsal 156 

176.  Osteomyelitis  with  invoKement  of  medullary  canal  and  cortical 

bone 160 

177.  Osteitis  with  an  extensive  periostitis 160 

178.  Acute  infection  in  the  joint  involving  the  femur 161 

179.  Compound  fracture  with  osteomyelitis 162 

180.  Osteomyelitis  with  sequestrum 162 

181.  X-ray  of  an  acute  osteomyelitis  one  week  after  onset 164 

182.  Chronic  osteomyelitis  with  new  bone  formation 165 

183.  New  bone  formation  showing  boundaries  of  infection 166 

184.  Exterior  deposition  of  bone  simulating  expanded  shaft 169 

185.  Chronic  osteomyelitis  with  sequestrum 168 

186.  Brody's  abscess  in  the  head  of  the  radius 168 

187.  Typical  tuberculosis  of  the  shaft  of  the  radius 169 

188.  Tuberculosis  of  one  side  of  the  epiphysis  of  the  tibia i~i 

189.  Tuberculosis  of  the  first  metacarpal  with  periostitis i~2 

190.  Tuberculous  osteomyelitis  in  an  infant  with  sequestrum 172 

191.  Luetic  periostitis  of  the  forearm 173 

192.  Luetic  periostitis  of  the  ulna  (lace  work  type) I73 

193.  Luetic  osteomyelitis  without  swelling  of  the  soft  tissue i"4 

194.  Involucrum  with  the  entire  shaft  becoming  a  sequestrum i"^4 

195.  Acute  osteomyelitis  with  no  involucrum 175 

196.  A  typhoid  periostitis  with  a  cavity  in  the  cortex 176 

197.  Raynaud's  disease  showing  appearance  of  terminal  phalanges. . .  17'^ 

198.  Leprosy 178 

1 99.  Leprosy i  "8 

200.  Coccidoidal  granuloma 179 

201.  Coccidoidal  granuloma I79 

202.  Coccidoidal  granuloma 179 

203.  Saucer-shaped  expansion  of  the  epiphyses  in  rickets 184 

204.  Saucer-shaped  expansion  of  the  epiphyses  in  rickets 184 

205.  Saucer-shaped  epiphyses  of  tibia  and  fibula  with  atrophy 185 

206.  Atypical  rachitic  changes 185 

207.  Atrophy  in  rickets  as  the  cause  of  multiple  fractures 186 

208.  Atalectatic  strips  of  consolidation  in  the  chest  from  rickets 187 

209.  Rachitic  condition  shown  by  faulty  calcification  in  epiphyses.  .  .  .  189 

210.  Congenital  lues  in  tibia  and  fibula 189 

211.  Periostitis  present  in  congenital  lues 190 

212.  Triimmer  zone  of  destruction  in  scurvy 191 


xvi  LIST  OF  ILLUSTRATIONS 

Figure  Page 

213.  Elevation  of  periosteum  and  organized  hemorrhage  in  scurvy. .  .  191 

214.  Beginning  organization  of  hemorrhage  under  torn-up  periosteum  192 

215.  Ossifying  hematoma  in  scurvy 193 

216.  Cod-iiver  oil  feeding  in  rickets  differentiated  from  scurvy 196 

217.  Rickets  after  cod-hver  oil  feeding 196 

218.  Healed  rickets  after  cod-hver  oil  feeding 197 

219.  Tuberculosis  of  the  knee  with  marked  hazing  and  atrophy 198 

220.  Non-tuberculous  infection  with  bone  production 199 

221.  Juvenile  deforming  osteochondritis  (Perthes' s  disease) 200 

222.  Juvenile  deforming  osteochondritis  (Perthes' s  disease) 201 

223.  Graphic  illustration  of  the  stages  of  bone  infection 206 

224.  Acute  polyarticular  arthritis 208 

22§.  Infectious  arthritis  in  the  first  stage 208 

226.  Second  stage  of  infectious  arthritis 210 

227.  Third  stage  of  infectious  arthritis 212 

228.  Tuberculous  arthritis  of  the  wrist 214 

229.  Tuberculous  arthritis  of  the  knee,  almost  healed 215 

230.  Caries  sicca  of  the  shoulder  joint  with  atrophy 216 

231.  Gonorrheal  arthritis  of  patella,  tibia  and  femur 217 

232.  Luetic  arthritis  with  periosteal  changes 218 

233.  Atrophic  arthritis  with  atrophy 219 

234.  Hypertrophic  arthritis  with  exostoses  and  joint  mice 220 

235.  Joint  mice  in  hypertrophic  arthritis 221 

236.  Synovial  thickening  in  villous  arthritis 224 

237.  Punched-out  areas  characteristic  of  gout  in  joints 226 

238.  Early  case  of  gout  with  punched-out  areas  missing 227 

239.  Charcot  joint  with  complete  destruction.  No  atrophy 228 

240.  Anteroposterior  view  of  Fig.  239 229 

241.  Charcot  joint  of  the  ankle  with  marked  periostitis 230 

242.  Hemorrhage  cysts  beneath  the  cartilage  of  the  joint 231 

243.  Hemophiliac  joint  with  surfaces  destroyed  by  hemorrhage 232 

244.  Organization  of  hemorrhage  in  elbow  joint 232 

245.  Bone  formation  in  the  tendo  Achillis  from  arthritic  condition.  .  .  234 

246.  Deposition  of  salts  in  the  subdeltoid  bursa 235 

247.  Deposition  of  salts  in  the  subdeltoid  bursa 235 

248.  Non-gonorrheal  type  of  exostosis  of  the  os  calcis 236 

249.  Gonorrheal  exostosis 236 

250.  Tumor  arising  within  the  medullary  canal.  (Giant-cell  sarcoma.) .  244 

251.  Tumor  arising  from  the  cortex.  (Fibromyxoma.) 245 

252.  Bone  production  within  a  tumor.  (Osteoma.) 246 

253.  Benign  tumor  with  slight  expansion  of  the  bone.  (Cyst.) 248 

254.  Benign  tumor  of  the  fibula.    (Cyst.) 249 

255.  Complete  destruction  of  the  head.  (Round-cell  sarcoma.) 250 

2^6.  Expansion    of  cortex    from    medullary  tumor.    (Giant-cell  sar- 
coma.)    25 1 


LIST  OF  ILLUSTRATIONS  xvli 

Figure  Page 

257.  Metastatic  carcinoma  showing  invasion 252 

258.  Metastatic  carcinoma  with  pathological  fracture 256 

259.  Carcinomatous  metastases  of  the  skull 257 

260.  Carcinoma  of  the  mandible 258 

261.  Metastasis  from  a  prostatic  carcinoma 259 

262.  Mihary  prostatic  metastases  of  the  lumbar  vertebrae 260 

263.  Round-cell  sarcoma  of  the  humerus 261 

264.  Spindle-cell  sarcoma  of  the  tibia 262 

265.  Advanced  case  of  periosteal  sarcoma 264 

266.  Periosteal  sarcoma  with  bone  striae  perpendicular  to  the  shaft. . .  264 

267.  Periosteal  sarcoma  wath  bone  striae  in  the  soft  tissues 265 

268.  Osteosarcoma  with  dense  bone  production 265 

269.  Giant-cell  sarcoma  with  cortex  intact 266 

270.  Giant-cell  sarcoma  with  spontaneous  healing 267 

271.  Lateral  view  of  Fig.  270 267 

272.  Multiple  enchondromata  of  medullary  and  cortical  origin 268 

273.  Osteochondroma  of  the  head  of  the  fibula 269 

274.  Large  osteochondroma  of  the  femur 270 

275.  Bone  cyst  of  the  humerus,  which  is  multilocular 2^2 

276.  Pathological  fracture  of  the  humerus  through  a  bone  cyst 2"2 

277.  Osteoma  showing  typical  cauliflower  growth 273 

278.  Osteoma 273 

279.  Table-top  type  of  exostosis 274 

280.  Pencil  type  of  exostosis  pointing  away  from  the  nearest  epiphy- 

sis    2''4 

281.  Exostosis  terminating  in  osteochondroma 2~5 

282.  Fibroma  of  the  phalanx 275 

283.  Hemangioma  with  calcified  bodies  in  the  soft  tissue 276 

284.  Hemangioma  of  the  hand 277 

285.  Ossifying  hematoma  of  the  femur 278 

286.  Myositis  ossificans 278 

287.  Osteosarcoma  with  bone  destruction 279 

288.  Osteitis  fibrosa  cystica  with  lengthening  of  the  tibia 281 

289.  Pressure  atrophy  of  the  cranial  bones  from  internal  pressure.  .    .  282 

290.  Destruction  of  the  sella  turcica  from  hypophyseal  tumor 283 

29 1.  Centers  of  ossification  of  the  vertebrae 290 

292.  Fracture  and  subluxation  of  the  second  cervical  vertebra 292 

293.  Fracture  of  the  transverse  process  of  the  lumbar  spine 293 

294.  Scoliosis  showing  primary  and  secondary  curves 294 

295.  Lateral  angulation  of  the  spine 295 

296.  A  fractured  spine  with  new  bone  production 296 

297.  Arthritis  with  edges  of  the  vertebrae  sharpened 298 

298.  Exostoses  along  the  vertebrae  and  lateral  ligaments 298 

299.  Destruction  and  fusion  of  two  vertebrae  with  angulation 299 

300.  Marie  Striimpell  type  of  arthritis  deformans 300 


xviii  LIST  OF  ILLUSTRATIONS 

Figure  Pa^-e 

301.  Charcot  joint  of  the  fourth  lumbar  vertebra 301 

302.  Carcinoma  of  the  lumbar  vertebra  with  joint  spaces  intact 303 

303.  Pressure  destruction  of  a  lumbar  vertebra  from  a  tumor 308 

304.  Rudimentary  vertebra  arising  from  the  seventh  cervical  vertebra  312 

305.  Cervical  rib  arising  from  one  side  only 313 

306.  Rudimentary  spina  bifida  of  the  seventh  cervical  vertebra 314 

307.  Rudimentary  vertebra  in  the  dorsal  region 314 

308.  Synostosis  of  the  bodies  of  two  ribs 315 

309.  Congenital  non-union  of  the  laminae  of  the  sacrum 315 

310.  A  pair  of  lumbar  ribs 316 

311.  Sacrolization  of  the  fifth  lumbar  vertebra 316 

312.  An  attempt  at  sacrolization  on  one  side 317 

313.  Aberrant  articulation  between  clavicle  and  coracoid 317 

314.  Absence  of  the  ulna  due  to  a  faulty  epiphysis 318 

315.  Extra  digit  arising  from  the  little  finger 318 

316.  Fourth  and  fifth  fingers  with  common  metacarpal 319 

317.  Extra  digit  on  the  toe 3^9 

318.  Congenital  absence  of  the  fibula 319 

319.  Osteitis  deformans 324 

320.  Osteitis  deformans 324 

321.  Changes  in  cranial  bones  in  osteitis  deformans 325 

322.  Acromegalic  skull 326 

323.  Changes  in  the  bones  of  the  hand  in  acromegaly 3^7 

324.  Osteomalacia 328 

325.  Osteomalacia 328 

326.  Achondroplasia 329 

327.  Achondroplasia  with  deformity  of  the  radius 330 

328.  Pulmonary  osteoarthropathy 331 

329.  Osteogenesis  imperfecta  with  multiple  fractures 332 

330.  Osteogenesis  imperfecta  with  multiple  fractures 333 

331.  Osteogenesis  imperfecta  with  multiple  fractures 333 


CHAPTER   I 
INTRODUCTION 


INJURIES  AND  DISEASES  OF 
THE  BONES  AND  JOINTS 

CHAPTER  I 

Introduction 

ROENTGENOLOGY  Is  of  comparatively  recent  ori- 
gin; only  within  the  last  decade  and  a  half  has  it 
made  its  greatest  progress.  Before  that  period  our 
b^  entire  energies  were  devoted  to  the  purely  mechan- 
ical side  of  developing  a  technique  so  that  examinations  could 
be  properly  made.  Today  one  hears  less  and  less  of  technique 
and  more  and  more  of  diagnostic  principles. 

Unfortunately  the  term  "picture"  has  been  introduced, 
not  in  the  sense  that  an  internist  would  use  it  when  he  speaks 
of  a  chnical  picture,  but  as  one  would  speak  of  a  photograph. 
There  is  no  such  thing  as  an  .v-ray  picture.  A  roentgenogram  is 
a  projection  upon  a  photographic  plate  of  a  series  of  shadows 
of  varying  density  representing  the  various  structures  through 
which  the  rays  have  passed.  The  correctness  of  the  diagnosis 
depends  entirely  upon  the  skill  with  which  these  various 
shadows  are  separated  and  interpreted.  To  interpret  these 
shadows  correctly  one  must  know  not  only  the  appearance  of 
the  normal  structure,  but  also  the  alterations  that  take  place 
when  there  is  a  pathological  process  present.  It  therefore 
follows  that  the  abihty  of  the  roentgenologist  depends  not  so 
much  upon  his  technical  skill  as  upon  his  famiharity  with  the 
general  problems  of  medicine  and  surgery. 

When  there  is  a  variation  from  the  normal  he  must  know 
whether  it  is  a  devek^pmental  process  or  the  result  of  disease. 
The  bone  of  a  child  differs  materially  from  that  of  an  adult. 
In  the  former  case  it  is  in  the  growing  stage,  and  too  often  a 
diagnosis  of  fracture  has  been  made  when  the  supposed  crack 

3 


4       INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

was  the  normal  epiphyseal  line.  A  thorough  knowledge  of  the 
anatomy  and  development  of  the  bone  would  have  obviated 
this  mistake.  The  reverse  of  this  has  occurred  where  a  linear 
crack  was  present  just  below  the  head  of  a  bone  in  an  adult 
and  was  interpreted  as  the  epiphyseal  line.  The  thinning  out  of 
the  cortex  on  the  internal  sides  of  the  radius  and  ulna  for  the 
attachment  of  the  interosseus  membrane  has  often  been  mis- 
taken for  a  periostitis.  So  it  may  be  said  that  the  first  requisite 
of  a  good  roentgenologist  is  a  thorough  knowledge  of  the  normal 
anatomj',  not  only  its  appearance  but  also  its  normal 
development. 

The  roentgenologist  should  also  be  so  thoroughly  ac- 
quainted with  every  phase  of  the  development  of  the  bone 
that  he  can  tell  the  approximate  age  of  the  individual  by  its 
appearance.  If  the  epiphysis  of  the  lower  end  of  the  radius  has 
united  at  fourteen  years,  or  is  still  present  at  twenty-five,  it 
may  possibly  give  the  clue  which  will  solve  a  very  obscure 
case.  Going  a  step  further,  the  roentgenologist  must  know  the 
constituent  parts  of  the  bones,  their  make-up  and  what  role 
they  play  in  the  normal.  He  must  be  thoroughly  familiar  with 
the  blood  and  lymph  supply,  as  that  shows  how  metastatic 
infection  or  malignancy  reaches  certain  portions  of  the  bone, 
and  why  other  portions  are  omitted.  In  the  same  way  he 
applies  his  knowledge  to  the  joints,  knows  their  constituent 
parts  and  what  role  each  part  plays.  If  he  knows  the  blood  and 
lymph  supply  of  the  cartilage  he  will  know  w  hy  in  cartilaginous 
lesions  the  infection  always  starts  from  the  periphery  and  never 
from  the  center  of  the  cartilaginous  mass. 

After  becoming  thoroughly  acquainted  with  the  histology 
of  the  normal  bone  and  the  functions  of  its  various  parts,  the 
roentgenologist  must  turn  to  the  pathological  side  and  know 
the  changes  that  take  place.  He  must  know  not  only  the  inti- 
mate structure  of  the  lesion,  but  also  its  method  of  progres- 
sion. This  does  not  occur  at  random,  but  follows  well-defined 
laws  based  on  the  character  of  the  lesion  and  on  the  roads  of 
transportation.  Having  learned  the  normal  and  pathological 


INTRODUCTION  5 

conditions  of  bone,  how  is  he  to  translate  them  into  what  may 
be  termed  A-ra}'  gross  histology  and  pathology,  for  after  all  if 
he  cannot  connect  the  lesion  with  the  x-ray  plate,  his  knowl- 
edge is  of  no  avail.  It  is  in  bridging  the  gap  between  these 
lesions  and  their  shadows  cast  upon  the  plate  that  the  expert 
knowledge  of  the  roentgenologist  comes  into  play. 

Only  two  pathological  processes  are  registered  upon  the 
plate;  bone  destruction  and  bone  reproduction.  The  con- 
sideration of  how^  and  when  these  processes  occur,  where  they 
are  situated,  and  their  relation  to  each  other,  enables  one  to 
make  a  diagnosis.  Bone  destruction  may  arise  from  some 
infection,  or  from  a  malignant  growth.  In  either  case  what  may 
be  termed  an  irritant  substance  is  introduced  into  the  bone. 
This  acts  as  an  exciting  agent,  and,  if  it  is  an  infection,  more  or 
less  destruction  of  bone  ensues,  depending  upon  its  virulence. 
If  the  irritant  is  of  a  benign  nature  it  stimulates,  and  there  is 
new  bone  formation  around  the  substance,  as  this  is  nature's 
way  of  taking  care  of  a  pathological  condition.  The  question 
will  present  itself  as  to  why  in  one  case  there  is  destruction 
and  in  the  other  bone  production.  The  point  of  contact  between 
the  lesion  and  the  bone  is  the  point  of  stimulation,  and  it  takes 
nature  some  little  time  to  lay  down  bone;  so  if  the  infection  or 
tumor  is  virulent  the  point  of  contact  is  swept  away  and  a  new 
one  formed  before  there  has  been  time  for  new  bone  formation, 
hence  the  process  is  entirely  destructive.  On  the  other  hand,  if 
the  point  of  contact  remains  stationary  for  a  short  period  then 
nature  has  time  to  lay  down  new  bone.  So  there  are  two  well- 
defined  changes  taking  place  in  bone,  namely,  destruction, 
indicating  an  advancing  lesion,  and  production,  indicating  a 
lesion  that  is  retrograding  and  probably  under  control. 

In  some  processes  there  is  continued  destruction  and  no 
bone  production,  indicating  that  the  lesion  is  a  rapidly  advanc- 
ing one  and  out  of  control.  This  is  seen  in  malignant  tumors, 
such  as  carcinoma,  round  and  spindle-cell  sarcoma  and  virulent 
infections.  The  nature  of  the  lesion  determines  the  character  of 
the     destruction.     An     osteomyelitic     infection     spreads     by 


6       INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

means  of  the  Haversian  canals  and  their  intersecting  rami- 
fications, and  thus  may  break  out  in  a  point  distant  from  the 
original  focus,  leaving  normal  bone  between.  On  the  other 
hand  growths  advance  by  direct  extension,  and  so  fresh 
foci  are  not  found  separated  from  the  parent  growth  with 
normal  bone  between.  The  character  of  the  destruction, 
therefore,  makes  it  possible  to  establish  one  point  of  differential 
diagnosis. 

The  production  of  bone  at  the  junction  of  the  lesion  and  the 
normal  bone  has  already  been  mentioned.  When  new  bone, 
then,  is  laid  down  at  the  edge  of  the  destroyed  area  it  is  in- 
dicative either  of  an  infection  or  of  a  benign  growth.  On  the 
other  hand  new  bone  is  sometmes  seen  within  the  lesion  itself 
where  there  is  normally  no  tissue  that  will  produce  bone. 
Such  a  condition  probably  indicates  a  bone  tumor  such  as  an 
osteoma  or  an  osteosarcoma.  Thus  a  second  point  of  differential 
diagnosis  is  established. 

When  the  lesion  is  in  the  medullary  canal  there  is  no  bone 
production,  but  vacuolated  areas  appear  in  benign  growths 
and  infections,  and  the  path  of  least  resistance  is  taken,  namely, 
up  and  down  the  canal,  while  malignant  tumors  grow  in  a 
spherical  manner  and  tend  to  destroy  the  cortex  by  pressure. 
So  a  third  point  of  differentiation  is  established — pressure 
effects,  and  the  manner  in  which  the  lesion  extends. 

The  above  points  may  be  termed  direct  evidence. 

Then  the  remote  effects  must  be  considered,  whereby  changes 
occur  in  the  bones,  not  directl}^  due  to  the  lesion,  but  rather  to 
mechanical  causes. 

When  some  process,  especially  an  infection,  involves  the 
bone,  there  is  generally  pain  with  consequent  inability  or 
lack  of  desire  to  use  the  particular  part  affected  on  account 
of  discomfort.  This  disuse  brings  about  a  condition  known  as 
atrophy,  which  is  not  due  to  disease,  but  is  entirely  a  disuse 
process.  It  is  seen  even  in  a  normal  bone  if  the  part  is  put  at 
rest.  The  calcium  salts  are  absorbed  and  a  very  porous  bone 
results.  Each  constituent  part  is  present,  but  in  much  dimin- 


INTRODUCTION  7 

ished  quantity.  This  process  is  entirely  functional,  and  the  bone 
will  quickly  return  to  normal  upon  use.  It  is  never  a  pathological 
condition. 

At  times  there  is  a  local  atrophy  following  a  pathological 
process.  In  fractures,  where  the  blood  vessels  are  destroyed, 
there  is  sometimes  actual  necrosis  of  the  bone  due  to  lack  of 
nourishment.  Atrophy,  then,  is  an  indication  of  disuse  of  the 
part,  and  thus  calls  attention  to  the  fact  that  some  cause 
must  be  found  for  its  presence.  As  an  example  of  this,  an 
examination  of  the  hip  was  requested  in  a  certain  case.  The 
plate  showed  no  lesion  in  the  joint,  but  that  portion  of  the 
femur  shown  upon  the  plate  disclosed  marked  atrophy. 
There  was  no  lesion  present  that  would  account  for  this 
condition.  In  discussing  the  case  with  the  surgeon  attention 
was  called  to  this  point,  and  the  statement  was  made  that 
for  some  cause  unknown  to  the  roentgenologist  the  femur 
must  have  been  at  complete  rest  for  a  long  period  of  time. 
This  elicited  the  information  that  there  had  been  fracture  of  the 
lower  third  of  the  femur,  and  that  both  femur  and  pelvis  had 
been  in  a  cast  for  nearly  twelve  weeks.  Atrophy,  therefore, 
is  a  functional  disuse  process,  and  its  presence  must  be 
accounted  for,  as  it  always  means  non-function  frequently 
due  to  disease.  On  the  other  hand  a  knowledge  that  atrophy 
is  absent  is  often  of  the  greatest  importance.  In  a  Charcot 
joint  the  plate  shows  swelling  and  extensive  destruction. 
In  any  other  condition  the  joint  would  be  painful  and  the 
part  could  not  be  used;  but  the  lack  of  atrophy  indicates 
that  the  joint  was  used,  and  hence  there  could  have  been  no 
pain.  Thus,  by  simple  logic  the  absence  of  pain  is  deduced  in  a 
badly  disorganized  joint  by  the  fact  of  the  absence  of  atroph\', 
and  a  diagnosis  is  established. 

So  far  the  changes  seen  upon  an  .v-ray  plate  have  been 
discussed,  and  they  may  be  termed  direct  evidence.  Are  there 
any  other  factors  that  may  be  obtained  which  will  aid  in  a 
diagnosis?  There  are  two  such  factors,  and  even  these  if  nec- 
essary may  be  deduced  from  the  plate  by  a  skilled  roentgen- 


8      INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

ologist.  However,  these  factors,  namely,  sex  and  age,  will  be 
considered  as  indirect  evidence. 

Certain  lesions  peculiar  to  the  female  are  seen  but  infre- 
quently in  the  males.  As  an  example,  separation  of  the  symphy- 
sis pubis  which  is  common  in  the  female  after  childbirth, 
is  but  rarely  seen  in  the  male  except  following  severe  trauma. 
Certain  fractures  are  much  more  common  in  the  male.  Certain 
metastatic  malignancies  have  a  different  l^one  distribution 
in  the  female  than  in  the  male. 

Again  aneurysms  are  relativeh^  uncommon  in  the  female. 
Consequently  destruction  of  the  vertebrae  due  to  pressure 
from  beneath  is  not  often  seen;  destruction  of  the  thoracic 
vertebrae  in  a  female,  therefore,  is  apt  to  be  malignant, 
while  in  the  male  in  the  same  region  it  may  be  a  pressure 
result. 

Age  has  a  very  important  bearing.  The  bones  differ  some- 
what at  different  ages,  and  the  resulting  injuries  from  trauma 
will  vary  according  to  age.  As  an  example,  take  the  same 
degree  of  injury  to  a  hip  and  see  what  follows  at  different 
age  periods.  In  the  young  an  epiphyseal  separation  of  the 
head  of  the  femur  results;  between  twenty  and  forty  years 
a  dislocation  is  produced;  and  after  forty  a  fracture  of  the 
neck  is  sustained. 

In  the  same  way,  if  there  is  a  malignant  growth  in  the 
bone  of  a  child  it  is  certain  that  it  is  not  a  carcinoma,  as  that 
is  an  old-age  disease.  A  joint  infection  in  early  youth  cannot 
be  a  hypertrophic  arthritis,  as  that,  too,  is  an  old-age  lesion. 
Rickets  and  scurvy  are  seen  only  in  the  first  few  years  of 
life.  So  laws  of  probabilities  as  to  sex  and  age  can  be  estab- 
lished. A  law  of  probability  also  may  be  determined  from  the 
portion  of  the  bone  in  which  the  lesion  is  situated,  thus  car- 
cinoma is  generally  found  in  the  middle  of  the  shaft  and 
sarcoma  at  the  ends.  These  probabilities  will  be  dealt  with  in 
the  succeeding  chapters. 

When  all  the  data  that  can  be  determined  from  the  plate 
are   obtained,    it    is   well    to   write   down    everj^   pathological 


INTRODUCTION  9 

condition  that  can  allcct  the  part  in  question.  Many  can  be 
eliminated  immediately,  but  some  few  will  still  remain.  In 
each  of  these  there  will  be  some  factor  that  does  not  fit  in 
with  the  plate,  and  finally,  by  exclusion,  the  fist  of  pathological 
conditions  will  be  narrowed  down  to  one.  Then  the  process 
must  be  reversed,  and  every  shadow  upon  the  plate  must 
coincide  with  the  lesion;  if  it  docs  not,  there  has  been  an 
error  which  must  he  sought  out.  It  is  only  when  they  agree 
that  we  may  feel  reasonably  sure  of  the  correctness  of  the 
diagnosis. 

As  has  been  stated,  roentgenology  is  not  a  picture  process, 
but  a  medical  procedure  based  upon  careful  analysis  and 
logical  deductions  from  the  shadows  observed  upon  an  .v-ray 
plate  and  translated  into  pathological  terms.  This  means — 
and  it  cannot  be  too  strongly  emphasized— that  the  skill  of  a 
roentgenologist  will  vary  directly  with  his  medical  knowledge; 
and  the  value  of  the  roentgenologist  to  the  medical  profession 
will  be  based  upon  this  fact  and  not  upon  his  technical  ability. 
It  must  also  be  borne  in  mind  that  roentgenology  is  but  one 
of  many  diagnostic  methods,  and  that  it  has  not  as  yet  reached 
a  stage  of  such  precision  that  it  may  be  considered  infallible. 

It  is  only  by  close  cooperation  with  his  colleagues,  in 
conjunction  with  his  medical  knowledge,  that  the  roentgenol- 
ogist can  advance  his  specialty.  He  has  four  friends  who 
are  only  too  willing  to  cooperate  with  him,  and  the  more 
intimately  he  associates  himself  with  them  the  better  will 
be  his  progress.  These  four  friends,  the  anatomist,  the  patholo- 
gist, the  internist  and  the  surgeon,  the  roentgenologist  should 
most  zealously  cherish  and  esteem. 


CHAPTER  II 
NORMAL  BONES 


CHAPTER  II 
Normal  Bones 

A  NORMAL  bone  is  composed  of  several  highl}'  organ- 
ized structures  having  different  functions.  Some  of 
these  are  plainly  seen  upon  an  .v-ray  plate,  and  others 
are  demonstrable  only  when  they  are  in  what  might  be  termed 
a  pathological  state.  This  is  particularly  true  of  such  a  struc- 
ture as  the  periosteum.  The  constituent  parts  of  the  bone 
vary  according  to  its  particular  type  and  also  according  to 
its  function;  for  example,  some  bones  have  a  shaft  and  car- 
tilaginous articulating  surfaces,  as  the  femur  or  tibia;  others, 
such  as  a  carpal  bone,  have  no  shaft  or  periosteum,  but  are 
irregular  in  shape  and  are  covered  entirely  by  cartilage.  \\  hile 
bones  may  vary  in  shape,  yet  they  are  composed  of  practically 
the  same  constituents  modified  according  to  the  use  to  which 
nature  intends  them  to  be  put. 

The  normal  constituents  are  as  follows: 
The  Periosteum.  This  is  a  fibrous  sheath,  rich  in 
blood  vessels,  covering  that  portion  of  the  bone  not  entering 
into  an  articulation.  This  structure  has  a  ver}^  important 
function,  as  it  is  one  of  the  bone  producing  elements,  and  its 
finely  divided  blood  vessels  penetrate  the  cortex,  thus  helping 
to  nourish  the  bone.  If  the  periosteum  is  torn  from  a  bone  we 
shall  find  the  cortex  studded  with  small  bleeding  points.  In 
the  young  this  sheath  is  quite  thick  and  very  vascular,  but 
is  loosely  attached  to  the  shaft  and  firmly  adherent  at  the 
epiphyses,  while  in  adults  it  is  firmly  attached  to  the  shaft. 
This  is  important  because  when  hemorrhage  takes  place 
beneath  the  periosteum  in  children  it  generally  surrounds 
the  entire  shaft,  as  the  periosteum  is  so  loosely  connected, 
while  on  account  of  the  firm  attachment  in  adults  the  Iiemor- 
rhage  is  generally  localized  to  one  j^art. 

13 


14     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

In  its  normal  state  the  periosteum  casts  no  shadow  upon 
the  plate  (Fig.  i),  but  in  its  pathological  state  there  is  invari- 
ably deposition  of  calcium  salts  (Fig.  2);  consequently  it  can 
be  easily  demonstrated.  Whenever  the  periosteum  is  visible 
upon  a  plate  it  indicates  an  abnormal  condition. 


Fig.   I. — A  section  of  a  normal  radius  and  ulna.  The  periosteum  cannot  be 
seen  as  the  calcium  salts  are  not  present  in  its  normal  state. 


The  Cortex.  Beneath  the  periosteum  we  come  to  dense, 
hard  bone,  called  the  cortex.  Fig.  3.  This  is  composed  of  bone 
cells  imbedded  m  masses  of  inorganic  salts  known  as  the 
matrix.  This  dense  bone  is  pierced  by  numerous  small  Haver- 
sian canals  ^^  hich  run  parallel  to  tlic  long  axis  of  the  bone  and 


NORMAL  BONES 


15 


are  united  by  numerous  intersecting  canals.  The  canals  play 
a  very  important  role  in  certain  diseases,  as  they  may  be 
termed  the  roads  of  transportation  for  the  infections.  At  the 
ends  of  the  bone  the  cortex  expands  into  fmely  reticulated 
bone,  rich  in  blood  and  lymph  vessels,  which  is  spoken  of  as 


Fig.  2. — The  deposition  of  calcium  salts  in  the  periosteum  on  the  internal 
aspect  of  the  tibia  clue  to  an  inflammatory  process  of  the  periosteum. 


cancellous  bone,  Fig.  4.  These  two  types  are  simply  variations 
in  the  amount  of  matrix  present,  there  being  more  in  compact 
bone  and  less  in  cancellous  bone.  The  cortex  and  the  cancellous 
bone  are  nourished  partly  by  minute  vessels  from  the  peri- 
osteum and  partly  from  the  medullary  artery. 


i6     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

The  Medullary  Canal.  Within  a  long  bone  there  is 
a  long  narrow  cylindrical  channel  known  as  the  medullary 
canal  (Fig.  5)  containing  the  marrow  fat,  nerves,  blood  and 
lumph  vessels.  From  an  .v-ray  standpoint  the  medullary 
canal  appears  as  a  hollow  channel,  as  its  contained  elements 


Fig.  3.— Note  the  dense  bony  cortex  of  the  tibia.  In  this  area  we  have  the 
bone  cells,  inorganic  salts  and  the  Haversian  canals. 


do  not  cast  shadows.  This  canal  does  not  traverse  the  entire 
bone,  but  merges  at  its  ends  into  the  cancellous  heads. 

The  Nutrient  Foramen.  At  approximately  the  middle 
point  of  the  shaft  is  the  nutrient  foramen,  an  aperture  which 
allows  the  big  vessels  to  enter  the  medullary  canal.  In  some 
bones,  such  as  the  femur,  there  may  be  two  such  foramina. 
While  this  foramen  cannot  be  demonstrated  by  the  A-ray,  yet 
it  is  of  great  importance,  as  it  is  the  entrance  by  which  metas- 


NORMAL  BONES 


17 


tatic    infections    and    malignancy   gain    admittance    to    the 
medullary  canal. 

Cartilage.  The  ends  of  the  bones  are  covered  by  a 
hyaline  material  called  cartilage.  This  is  a  dense,  hard  structure 
free  from  vessels.  It  varies  in  thickness,  being  thicker  at  its 


Fig.  4. — There  is  no  cortex  present  at  the  end  of  the  bones;  it  and  tlie 
medullary  canal  fuse  and  form  a  linely  reticulated  bony  structure 
rich  in  blood  vessels. 


weight-bearing  points,  that  is,  its  convex  portion,  and  thinner 
at  its  concave  portion.  The  hgaments  of  the  joints  are  imbedded 
in  it.  When  there  is  infection,  the  thinnest  portion  is  destroyed 
hrst,  therefore  bone  changes  must  be  sought  in  those  areas. 
Joint  cartilage  does  not  undergo  cak^ificatiou,  Fig.  6.  It 
has  poor  recuperative  power,  and  when  cak'ilication  is  present 
it  means  that  the  cartikige  has  been  destroyed  and  replaced 


i8     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

by  bone  tissue.  In  other  types  of  cartilage,  such  as  the  costal 
cartilage  (Fig.  "),  calcification  is  a  normal  change  due  to  age 
but  this  never  takes  place  in  a  joint.  As  cartilage  does  not 
contain  blood  or  lymph  vessels,  metastatic  infections  and 
malignancv  are  not  found  in  this  tissue. 


Fig.  5. — \\ithin  the  center  of  the  bone  there  is  the  medullary  canal  con- 
taining the  ner\-es,  blood  and  lymph  vessels,  and  the  marrow  fat. 
This  canal  appears  as  a  hght  channel  upon  the  print. 

Variations  in  bone  architecture  are  due  to  differences  in 
combinations  of  compact  and  cancellous  tissues  and  the 
mechanical  distribution  of  cartilage.  We  can,  therefore, 
classify  the  bones  as  follows : 

I.  Long  bones. 


NORMAL  BONES 


19 


Fig.  6. — The  space  between  the  bones  is  tilled  with  cartihige  whicli  casts 
no  shadow.  This  type  of  cartilage  does  not  undergo  calcification  with  age. 


Fig.  7. — Tins  shows  a  diflerent  t>pe  of  cartilage  present    in   the  costal 
cartilages  which  normally  undergo  calcihcation  with  acKancing  age. 


20     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

2.  Flat  bones. 

3.  Irregular  bones. 

The  long  hones  (Fig.  8)  are  made  up  of  all  the  structures  just 


Fig.  9. — A  flat  bone  showing  its  cancellous 
structure,  and,  incidentally,  the 
grooves  for  the  blood  vessels. 


Fig.  8. — Tibia  and  fibula, 
showing  cortex,  medul- 
lary canal  and  cancel- 
lous bone. 


Fig.  10. — Carpal  bone  composed  entirely 
of  cancellous  tissue  with  a  very  thin 
cortex.  This  bone  comes  under  the 
head  of  what  might  be  termed  the 
irregular  bones. 


described,  and  may  be  the  seat  of  fractures  and  disease  not 
only  of  the  shaft,  but  also  of  the  joints,  so  both  bone  and  joint 
lesions  may  be  present. 


NORMAL  BONES  21 

The  flat  hones  (Fig.  9)  have  slightly  diflercnt  architecture. 
There  is  no  medullary  canal,  but  the  bone  is  made  up  of  cancel- 
lous tissue  lying  between  two  thick  plates  of  compact  bone. 
There  may  or  may  not  be  joint  cartilage  present.  Examples  of 
this  type  are  the  innominate  bones,  scapulae,  ribs,  and  the 
cranial  bones.  The  first  two,  having  articular  cartilage,  may 
be  the  seat  of  either  bone  or  joint  lesions,  while  the  latter  two 
are  only  subject  to  bone  lesions. 

The  irregular  hones  (Fig.  10)  such  as  the  carpals  and  tarsals, 
are  entirely  cancellous  and  have  a  cortex  of  a  very  thin  compact 
layer  of  bone;  some  of  them  are  entirel}^  covered  with  cartilage, 
as  the  carpal  bones,  or  are  partially  covered,  as  the  os  calcis. 
So  with  some  of  the  bones,  those  covered  entirely  with  cartil- 
age, only  those  lesions  occur  which  may  be  termed  joint 
diseases,  while  others,  as  the  os  calcis,  are  subject  to  both  bone 
and  joint  diseases. 

The  vertebra  may  also  be  looked  upon  as  an  irregular  bone; 
the  upper  and  lower  borders  are  covered  with  cartilage,  and 
the  sides  with  periosteum;  so  here  also  both  bone  and  joint 
lesions  may  be  present. 

Joints.  In  a  joint,  which  may  be  defined  as  the  junction  of 
two  bones,  a  totally  different  condition  prevails.  No  periosteum 
is  present,  but  there  are  more  or  less  large  articulating  cartil- 
aginous surfaces  and  a  capsular  covering  enclosing  the  joint 
known  as  the  synovial  membrane.  The  synovial  membrane  is  a 
fibrous  tissue  sheath,  but,  unlike  the  periosteum,  is  incapable 
of  producing  bone.  In  a  joint  there  are  no  normal  elements 
which  will  produce  bone.  Therefore  whenever  bone  is  formed 
in  a  joint  it  is  the  result  of  destruction  of  cartilage  and  exposure 
of  raw  bone  which  then  proliferates.  Nearly  all  the  elements 
of  a  normal  bone  are  directly  demonstrable,  while  the  elements 
of  the  normal  joint  cannot  be  seen.  In  bone  there  is  direct 
evidence  of  destruction,  while  in  joints  only  indirect  evidence  is 
obtained,  and  the  destruction  must  go  on  until  the  bone 
beneath  is  involved  before  direct  evidence  appears.  As  has 
been  stated,  cartilage  casts  no  shadow;  howe\er,   the  space 


22     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

between  two  joint  surfaees  is  filled  with  cartilage  (Fig.  ii) 
and  when  this  space  is  narrowed  (Fig.  12)  it  shows  that  cartil- 
age has  been  partially  destroyed;  thus  we  have  w^hat  is  termed 
indirect  evidence  of  cartilage  destruction.  When  cartilage  is 
involved  it  is  bj^  direct  contact  either  from  the  joint  space  or 
from  the  bone  beneath.  The  lesion  can  never  start  from  within 
the  cartilage  mass,  as  there  are  no  vessels  to  carry  in  the 
infection. 


Fig.   II,  Fig.   12. 

Fig.  II. — Normal  space  between  the  bones  filled  with  cartilage. 

Fig.   12. — Partial  destruction  of  cartilage,  indicated  by  narrowing  of  the 

joint   space. 

Growth.  Thus  far  the  discussion  has  been  limited  to  a 
bone  that  has  reached  its  full  growth.  Up  to  the  age  of  epi- 
physeal union  the  bones  differ  very  materially.  Since  bones 
have  to  grow,  as  does  other  tissue,  and  as  they  are  rigid,  fixed 
structures,  some  mechanism  must  be  present  that  will  allow 
them  not  only  to  lengthen,  but  also  to  expand.  The  expansion 
is  very  simple,  being  due  largely  to  bone  being  laid  down  by  the 
periosteum.  This  is  done  so  insidiously  that  it  cannot  be  dem- 


NORMAL  BONES 


23 


onstrated.    It  may  be  likened  to    the  constant  replacement 
of  skin  epithelium. 

To  allow  bones  to  lengthen  nature  has  placed  at  each  end 
of  nearly  all  of  them  a  very  highly  organized  mechanism  known 
as  the  epiphysis.  When  the  bones  first  appear  in  fetal  life  they 
are  composed  entirely  of  cartilage,  but  soon  centers  of  ossifica- 
tion appear  and  the  cartilage  is  gradually  transformed  into 
bone.  At  birth  all  the  long  bones  are  fully  developed,  except  as 


Fig.    13.  Fig.    14. 

Fig.  13. — A  knee  joint  at  a  very  early  age,  showing  center  of  ossification 
for  the  lower  end  of  the  femur.  The  upper  end  of  the  tibia  is  composed 
entirely  of  cartilage,  the  ossified  center  not  having  appeared.  Note  the 
enormous  width  of  joint  space,  composed  entirely  ol  cartilage,  which 
casts  no  shadow. 

Fig.  14. — The  wrist  of  a  child  of  seven  showing  the  wide  epiphyseal  hnes. 
Note  particuLirlv  the  epiphyseal  hnc  of  the  hrst  metacarpal  and  com- 
pare with  Fig.  15. 

to  size,  with  the  exception  of  each  end,  and  there  the  heads 
are  composed  entirely  of  cartilage,  Fig.  13.  At  various  ages, 
centers  of  ossification  in  the  l)one  heads  appear  (Fig.  14)  and 
increase  in  size,  but  do  not  unite  until  full  growth  has  finally 
been    attained.    There    is    consequently    a    point    where    the 


24     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

bone  and  ossified  heads  are  united,  but  it  is  by  a  cartilaginous 
band  which  is  wide  in  the  young  and  becomes  narrower  with 
age,  Fig.  15.  It  finally  disappears  bj'  union  with  the  shaft  when 
full  growth  is  attained,  and  under  normal  conditions  the 
growth  then  ceases.  This  band  of  cartilage  lays  down  new  bone 
which  causes  the  shaft  to  lengthen,  and  at  the  same  time 
reproduces  its  own  tissue.  W  hen  it  ceases  to  reproduce  its  own 
tissue  then  union  takes  place.  This  band  is  known  as  the  epi- 


FiG.  15. — A  child  of  eleven  years.  The  epiphyseal  line  of  the  first  meta- 
carpal has  become  quite  narrow  as  this  epiphysis  unites  at  fourteen. 
The  epiphyseal  Une  of  the  radius  is  still  quite  distinct  as  it  does  not 
unite  until  eighteen. 

phj-seal  line,  and  is  easily  demonstrable  by  the  .v-ray.  Any 
interference  at  this  epiphyseal  line,  either  by  disease  or  injury, 
is  attended  with  serious  consequences  to  the  particular  bone 
involved.  There  are  certain  diseases  in  which  the  epiphyses  are 
subject  to  either  excess  or  retarded  growth,  and  profound 
changes  are  invariably  the  result  of  these  conditions. 

Joint  Lesions.  While  the  bone  is  growing  it  always 
retains  its  mechanical  shape,  and  thus  lesions  up  to  puberty  are 
similar  to  those  of  adults.  The  joint  lesions,  however,  are  more 


NORMAL  BONES  25 

difficult  to  discern,  as  the  heads  are  composed  largely  of  car- 
tilage which  does  not  cast  a  shadow  and  consequently  there 
may  be  various  lesions  which  cannot  be  recognized  by  direct 
x-ray  evidence.  In  an  adult  a  fracture  of  the  head  of  the 
humerus  can  be  readily  demonstrated,  while  in  a  newborn  child, 
the  head,  being  composed  of  cartilage  (Fig.  16),  may  be  broken 
or  pulled  off  completely  and  yet  not  be  recognized.  It  is  the 
writers'   belief  that  many  of  the  so-called  congenital  abnor- 


FiG,  16. — The  head  of  the  humerus  of  a  newborn  ehild.  The  entire  head 
is  composed  of  cartilage  and  may  be  injured  and  yet  not  be  recognized 
by  means  of  an  x-ray  examination. 


malities  are  in  reality  injuries  to  the  cartilage  after  birth,  and 
that  the  resulting  deformity  is  due  to  faulty  growth  or  mal- 
position of  the  cartilaginous  fragment.  Complete  displacement 
of  an  epiphysis  results  in  non-growth  of  that  portion  of  the 
bone.  These  epiphyseal  injuries  are  so  often  unrecognizable 
both  clinically  and  roentgenologically  at  the  time  of  injury 
that  when  later  in  life  such  a  condition  is  seen  it  may  be 
considered  as  congenital  in  origin.  It  may  be  stated  almost  as 
an  axiom  that  l^cforc  joint  lesions  in  children  can  be  demon- 


26     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

strated   by   means   of  the  .v-ray   they   must   always  be  more 
advanced  than  in  adults. 

Thus  far  it  has  been  shown  that  in  normal  bones  and  joints 
there  are  definite  variations  between  those  of  children  and  of 
adults,  and  that  these  variations  may  materially  influence  and 
aid  in  bringing  about  pathological  conditions.  The  question 


\ 


Fig.   17. — The  shoulder  joint  in  a  man  of  fifty,  showing  atrophy  from  age. 
In  this  condition  the  bones  are  quite  brittle,  and  fracture  easily. 


naturally  arises  \\hether  there  are  any  variations  after  the 
bones  and  joints  have  attained  their  full  growth.  The  varia- 
tions in  youth  can  be  classed  as  developmental.  In  adults  there 
are  no  such  changes;  the  bones  have  ceased  growing.  However, 
in  adults  there  are  alterations  in  some  of  the  constituent 
parts.  It  may  be  roughly  stated  that  the  bones  reach  their  full 
growth  at  twenty,  and  that  from  this  age  up  to  forty  no  change 
of  anv   character  can  be   noted.   This   is  our  most   vio;orous 


NORMAL  BONES  27 

period  of  life  and  our  bones  should  be  at  their  best.  After  forty 
we  begin  to  slow  up  somewhat  and  this  can  be  noted  in  our 
bones.  Certain  changes  begin  to  take  place,  which  may  be 
termed  retrograde,  very  shght  at  forty,  but  increasing  with 
age.  Up  to  forty  our  bones  are  dense,  due  to  the  inorganic 
salts,  flexible  and  more  resistent  to  stress  and  strain.  After 
forty  they  gradually  lose  their  nexibihty  and  become  some- 
what brittle.  Fig.  17.  In  children  green-stick  fractures  are 
common  owing  to  the  flexibility  of  the  bones;  but  in  old  age  the 
fractures  are  always  complete  and  sometimes  comminuted  as 
the  flexibihty  has  disappeared,  leaving  a  more  brittle  bone. 
This  is  due  to  a  gradual  absorption  of  hme  salts,  so  that  the 
bone  becomes  more  atrophic  and  ofl"ers  less  resistance  to 
injuries  and  diseases.  This  atrophic  condition  is  readily  recog- 
nized upon  an  .v-ray  plate.  There  are  certain  types  of  fractures 
occurring  after  the  age  of  forty  which  are  extremely  rare  below 
that  age.  Thus  the  hfe  of  the  bone  may  be  regarded  as  having 
three  distinct  phases: 

1.  Up  to  the  age  of  twenty;  the  stage  of  progressive  de\el- 
opment. 

2.  From  twenty  to  forty;  the  stage  of  greatest  de\cIopmcnt 
and  strength. 

3.  From  forty  on;  the  stage  of  retrogression  and  weakening 
of  the  bone  structures. 

Effect  of  Sex.  The  second  question  to  be  considered 
is  whether  there  are  any  changes  in  the  structure  of  the  bones 
in  the  male  that  make  them  difler  from  those  of  the  female. 
The  bones  of  both  sexes  are  identical  as  far  as  structure  is 
concerned,  except  that  as  a  rule  those  of  the  female  arc  shorter 
and  narrower;  but  in  proportion  to  their  size,  they  are  as 
strong  as  those  of  the  male.  The  arrangement  of  the  bones  may 
be  slightly  modifled  in  the  female  to  accommodate  them  to 
functions  peculiar  to  that  sex.  The  pelvis  (Fig.  18)  wiH  dem- 
onstrate this  point.  In  the  female  the  sacrum  occupies  a  high 
position,  so  that  its  top  plane  is  on  a  level  or  just  sHghtly  below 
a  plane  passed  through  the  crests  of  the  iha.  This  causes  a 


28     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  1 8. — The  pelvis  of  a  female.  Note  the  high  position  of  the  sacrum 
with  the  corresponding  position  of  the  fifth  hmibar  in  relation  to  the 
crest  of  the  iha. 


NORMAL  BONES 


29 


Fig.   19. — The  deep-set  sacrum  of  a  male.  Again  note  tlie  position  of  the 

fifth  hmihar  in  relation  to  the  liia. 


30     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

Ilaring  out  of  the  iliac  bones  and  gives  a  wider  and  deeper 
pelvic  canal,  which  in  turn  slightly  alters  the  angle  that  the 
femur  makes  with  the  pelvis.  In  the  male  (Fig.  19)  the  plane  of 
the  iliac  crests  passes  through  the  middle  or  top  of  the  fifth 
lumbar  vertebra,  resulting  in  a  narrow  pelvis. 

It  is  reasonable  then  to  conclude  that  age  and  sex  have  a 
definite  relationship  to  normal  bones,  and  that  they  also  have 
an  effect  upon  the  bone  lesions  when  they  occur. 

In  the  following  chapters  injuries  and  diseases  will  be 
studied  from  the  standpoint  of  sex  and  of  the  three  age  periods 
that  have  been  enumerated. 


CHAPTER  III 
EPIPHYSES 


CHAPTER  III 

Epiphyses 

IN  roentgenological  diagnosis  it  is  very  important  to  have 
a  thorough  knowledge  of  the  epiphyses  of  the  bones. 
This  portion  of  the  bone  plays  such  an  important  part  in 
the  growth  and  is  so  easily  affected  by  injur}-  and  disease,  that 
all  the  normal  changes  which  occur  up  to  the  time  of  its 
union  with  the  shaft  should  be  thoroughly  understood.  It 
must  be  known  therefore,  at  what  time  the  center  of  ossifica- 
tion appears,  the  appearance  of  the  epiphysis  at  various 
ages,  and  finally,  the  period  when  it  unites  and  becomes 
an  integral  part  of  the  bone.  The  age  of  a  child  of  average 
development  can  be  approximately  determined  by  the  absence 
of  the  centers  of  ossification  or  by  the  size  of  the  ossified 
centers  when  present.  This  is  very  important  diagnostically 
as  some   injuries   and   diseases   are   limited   to   certain   ages. 

It  must  be  remembered,  however,  that  the  development  of 
the  epiphysis  is  somewhat  variable,  being  influenced  b}"  a 
number  of  conditions.  Nutrition  is  probably  one  of  the  greatest 
factors.  It  has  been  the  general  experience  that  in  undeveloped 
and  poorly  nourished  children,  the  growth  of  the  centers  of 
ossification  is  very  materiall}'  retarded.  It  must  also  be  borne  in 
mind  that  the  epiphyses  in  the  newborn  are,  for  the  most 
part,  composed  entirely  of  cartilage,  and  since  cartikige  does 
not  cast  a  shadow  it  cannot  be  demonstrated  by  an  .v-ray  exami- 
nation. Fig.  20.  It  is  only  when  the  center  of  ossification 
appears  that  information  can  be  obtained.  Fig.  21.  \\c  then 
judge  of  its  size,  position  and  contour  to  determine  whether 
it  is  normal,  pathok)gicaI,  or  has  been  the  seat  of  an  injur\ . 

It  has  been  noted  that  mahiutrition  retards  the  develop- 
ment of  the  epiphysis,  and  that  in  the  normal  indi\"idual,  there 
is  a  wide  variation  in  the  time  of  appearance  of  the  centers  of 
3  33 


34     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


y. 


Fig.  20.  Fig.  21.  Fig.  22. 

Fig.  20. — A  child  of  eighteen  months  with  only  two  centers  of  the  carpal 

bones  showing. 
Fig.  21. — A  child  of  three   years  showing  three  centers  of  ossification  of 

the  carpal  bones. 

Fig.  22. — A  child  of  ten  years  with  delayed  ossification.  None  of  the  carpal 

bones  are  developed  as  fully  as  they  should  be  at  this  age. 


I 


Fig.  23. — A  child  of  fifteen  years  with  the  center  of  ossification  of  the 
epiphysis  of  the  acromion  just  appearing.  Sometimes  mistaken  for  a 
fracture. 


EPIPHYSES  35 

ossification  (Fig.  22)  and  the  time  of  fusion.  For  practical  pur- 
poses only  those  centers  of  ossifications  which  appear  after  birlh 
need  be  considered. 

Scapula.  The  scapula  has  seven  centers  of  ossification  of 
which  but  three  need  be  mentioned  here.  They  are  the  center 
for  the  coracoid  process,  the  center  for  the  outer  end  of  the 
acromial  process,  and  that  for  the  inferior  angle  of  the  body 
of  the  scapula.  The  coracoid  center  appears  at  the  end  of  the 


Fig.  24. — A  child  of  four  years,  showing  separate  centers  of  ossification 
for  tlie  head  of  the  humerus.  Tliese  fuse  into  one  solid  head  at  about 
the  sixth  year. 

first  year  and  unites  at  about  the  fifteenth  year.  The  outer  end 
of  the  acromion  (Fig.  23)  has  one  and  sometimes  two  centers 
appearing  about  the  fifteenth  year  and  fusing  about  the 
eighteenth.  The  center  for  the  inferior  angle  appears  at  the 
age  of  fifteen  and  fuses  at  about  eighteen.  These  epiphyses 
are  sometimes  mistake?!  for  Jraclures. 

Clavicle.     The  sternal  end  of  the  clavicle  has  a  separate 
center  which  appears  from  the  fifteenth  to  the  se\cnteeiith 


36     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

year  and  fuses  at  the  twenty-third  to  the  twenty-iifth.  This 
epiphysis  is  seldom  of  pathological  interest,  but  is  a  good 
index  in  determining  the  age  of  a  patient. 

Humerus.  The  upper  end  of  the  humerus  has  three 
centers:  the  head,  appearing  at  the  sixth  or  eighth  month; 
and  the  greater  and  lesser  tuberosities,  appearing  from  the 
third  to  the   fourth  year,  Fig.  24.  These  unite  at  about  the 


Fig.  25. — The  epiphyses  around  the  elbow  joint  at  the  fourteenth  year. 

sixth  year  into  one  big  epiphysis.  This  epiphysis  is  of  great 
importance,  as  it  is  a  common  seat  of  injury  and  disease. 
The  lower  end  of  the  humerus  has  four  centers  (Fig.  25) ; 
(i)  the  capitelkim,  appearing  at  one  year;  (2)  the  internal 
condj'le,  at  five;  (3)  the  trochlea,  at  ten  to  eleven;  and  (4)  the 
external  condyle,  at  twelve  to  fourteen.  They  remain  as 
separate  centers  until  the  age  of  sixteen  to  seventeen,  and 
then  unite  as  a  mass  and  fuse  at  the  eighteenth  or  nineteenth 
year.  The  lower  epiphysis  figures  very  largely  in  injuries  at 
the  elbow  joint  in  the  first  ten  years  of  life. 


EPIPHYSES 


37 


Fig.  26. — The  lower  epiphysis  of  the  radius.  This  epiphysis  is  a  very 
important  one  as  it  is  so  frequently  torn  off  and  displaced  backward. 


Fig.  27. — The  epiphysis  of  the  olecranon  at  the  fifteenth  year.  This  is 
important  as  it  is  occasionally  torn  off. 


38     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

Radius.  The  center  for  the  head  of  the  radius  appears 
about  the  fifth  and  unites  at  the  sixteenth  to  seventeenth 
year.  This  epiphj'^sis  is  seldom  injured.  The  lower  epiphysis 
appears  about  the  second  year  and  unites  at  the  seventeenth 


Fig.  28.  Fig.  29.  Fig.  30. 

Fig.  28. — A  child  of  four  years  with  four  centers  of  ossification  of  the 

carpal  bones. 
Fig.  29. — A  child  of  seven  years  with  seven  centers  of  ossification  of  the 

carpal  bones. 

Fig.  30 — A  child  of  eleven  years.  The  center  of  ossification  of  the  pisiform 

is  now  present,  appearing  between  the  eighth  and  eleventh  year. 

or  eighteenth.  This  is  also  a  very  important  epiphysis,  as  it  is 
so  frequent!}'  dislocated,  Fig.  26. 

Olecranon.  The  olecranon  center  appears  at  eight  or 
nine  and  fuses  at  seventeen.  It  is  subject  to  frequent  injuries. 
Fig.  27.  The  lower  epiphysis  appears  at  the  fourth  and  fuses 
at  the  eighteenth  year  and  is  seldom  injured. 

Carpal  Bones.  The  carpal  bone  centers  appear  in  the  fol- 
lowing order:  os  magnum,  unciform,  cuneiform,  semilunar, 
trapezium,  scaphoid  and  trapezoid;  and  a  good  working  rule 
is  that  they  appear  one  for  each  year  in  the  order  named  above 
(Figs.  28  and  29),  the  center  for  the  pisiform  appearing  between 
the  eighth  and  eleventh  year.  Fig.  30.  The  metacarpal  centers 
appear  about  the  third  and  fuse  at  the  seventeenth  to  eigh- 
teenth year. 

Phalanges.  The  phalangeal  centers  also  appear  about 
the    third   year   and    fuse   at   the   sixteenth   or   seventeenth. 

Pubis   and    Ischium.     The   pubis   and    ischium    unite   at 


EPIPHYSES 


39 


from  seven  to  nine  (Fig.  31)  and  the  acetabulum  fuses  at 
fifteen  to  sixteen.  The  center  for  the  crest  of  the  ihum  appears 
at  from  fifteen  to  eighteen  years  and  fuses  at  twenty-three  to 
twenty-five. 


Fig.  31. — The  pubis  and  ischium  unite  at  from  seven  to  nine  >ears.  Tliis 
plate  of  a  child  of  five  shows  that  complete  ossification  has  not  taken 
place. 

The  centers  for  the  ischial  tuberosity,  the  iliac  spine  and 
tubercle  of  the  pubes,  appear  at  fifteen  and  unite  at  twenty 
and  are  of  little  pathological  importance. 

Femur.  The  center  for  the  head  of  the  femur  (Fig.  32) 
appears  at  the  first  year  and  fuses  at  seventeen  to  eighteen. 
The  epiphysis  is  of  great  importance,  as  it  is  frequently  dis- 
located. 

The  greater  trochanter  appears  at  the  fourth  and  unites  at 


40     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  eighteenth  year.  The  lesser  trochanter  appears  at  the 
eleventh  to  thirteenth  year  and  unites  at  seventeen.  The 
center  for  the  lower  epiphysis  of  the  femur  appears  at  birth 
(Fig.  33)  and  unites  at  eighteen  to  twenty  years.  This  epiphysis 
is  important,  as  it  is  sometimes  dislocated. 

Patella.     The   patella   center   appears   at   the   third   to 
fourth  year,  Fig.  34. 


Fig.  32. — A  child  of  nine  jxars  showing  the  epiphysis  of  the  greater  tro- 
chanter. The  lesser  trochanter  is  not  present  as  the  ossified  center  does 
not  appear  until  the  eleventh  year. 


TiBLA.  AND  Fibula.  The  center  for  the  upper  epiphysis  of 
the  tibia  (Fig.  35)  appears  in  the  latter  half  of  the  first  year 
and  unites  at  eighteen  or  twenty  and  is  but  rarely  separated. 
The  lower  center  appears  at  about  two  and  unites  at  seventeen 
or  eighteen  years  and  is  subject  to  injuries.  The  upper  center  for 
the  fibula  appears   at  three  to  four  and  unites  at  eighteen  to 


EPIPHYSES  41 

twenty-five  j^ears.    The  lower  epiphysis  appears  at  two  and 
unites  at  seventeen  to  eighteen. 

The  centers  for  the  os  calcis,  astragalus  and  cuboid  appear 
before  birth  (Fig.  36);  the  external  cuneiform  at  one  year; 
internal  cuneiform  at  the  third  year;  the  middle  cuneiform  and 
scaphoid  at  the  fourth  year.  The  separate  center  of  the  pos- 
terior extremity  of  the  os  calcis  appears  at  the  tenth  and  unites 


^ 


Fig.  33. — A  child  under  six  months,  showing  the  center  of  the  epiphysis 
of  the  lower  end  of  the  femur  which  is  present  at  birth.  The  center 
for  the  upper  end  of  the  tibia  is  not  present  as  it  does  not  appear  until 
the  last  six  months  of  the  first  year. 

at  the  eighteenth  year.  The  centers  for  the  metacarpals  and 
phalanges  vary  in  their  appearance  from  three  to  seven  years 
and  unite  at  about  seventeen. 

For  practical  purposes,  it  may  be  accepted  that  with  the 
exception  of  the  head  of  the  fibula,  which  fuses  after  twenty 
years,  union  of  the  epiph3'ses  of  the  long  bones  takes  place 
approximately  at  eighteen  years. 

Vertebrae.  Vertebrae  (Fig.  37)  arise  from  three  centers, 
one  for  the  body  and  one  for  each  lamina.  These  are  almost  fully 
developed  at  birth;  in  the  first  jxar  the  laminae  unite  and  at 
the  third  year  the  body  and  the  arch  join.  At  the  sixteenth  year 
secondary  centers  appear,  one  for  the  tip  of  each  transverse 
process  and  one   for  the  spinous   process.   At   twenty-one  a 


42     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

thin  circular  plate  of  epiphyseal  bone  forms  in  the  cartilage 
between  the  vertebrae,  one  above  and  one  below  each  vertebra 
and  unites  between  the  twenty-fifth  and  thirtieth  year.  These 
epiphyses  seldom  play  any  part  in  injuries,  but  by  variations 
in  ossification  they  produce  al3normantics,  as  in  sacrahzation 
of  the   fifth   himbar   \ertebra,    where   there   has    been    over- 


FiG.  34.  Fig.  35. 

Fig.  34. — The  center  for  the  patella  appears  at  the  fourth  jear.  The  age 
of  this  patient  is  about  nine  years  and  the  patella  has  not  reached  its  full  size. 
Fig.  35. — The  well-developed  head  of  the  tibia  at  eight  years. 

development  of  one  of  the  lateral  masses.  The  reverse  of  this  is 
seen  where  the  lateral  mass  on  one  side  of  the  fifth  lumbar 
vertebra  is  under-developed  and  a  scoliosis  results. 

These  variations  in  the  normal  process  of  development  and 
union  of  the  epiphyses  are  important  factors  in  the  production 
of  deformities.  Certain  diseases  of  infancy,  notably  rickets, 
lues  and  scurvy,  affect  the  epiphyses,  retarding  growth  and 
producing  deformities.  Then  again,  in  cretinism  and  infantil- 
ism   there    is   marked   delay   in   the   union   of  the   epiphyses. 


EPIPHYSES 


43 


In  cases  of  the  latter  condition  all  the  epiphyses  have  been 
seen  as  late  as  the  age  of  thirty.  In  the  various  types  of  chon- 
drodystrophies the  reverse  takes  place;  the  epiphyses  unite 
at  a  much  earlier  age  than  normal,  and  consequently  the  bones 
are  much  shorter,  but  the  periosteal  growth  continues  until 
the  bones  reach  their  normal  width. 


Fig.  36.  Fig.  37. 

Fig.  36. — Showing  the  centers  of  the  ankle  joint  present  at  birth.  Tlie 

space  between  the  leg  bones  and  metatarsals  is  filled  with  cartilage. 

Fig.  37. — Note  the  three  centers  present  in  the  vertebrae,  one  for  each 

lateral  mass  and  one  for  the  body. 


There  are  certain  variations  as  to  the  position  ot  the 
epiphyses  that  must  be  borne  in  mind.  The  thumb  metacarpal 
has  its  epiph3'sis  at  the  proximal  end,  while  the  remaining 
four  have  their  epiphyses  at  the  distal  end.  This,  taken  into 
consideration  with  the  fact  that  all  the  phalanges  have  their 
epiphyses  at  the  proximal  end  and  that  the  thumb  has  only 
two  phalanges,  suggests  that  the  thumb  metacarpal  is  in  reality 
a  phalanx.   Fig.  38.  This  condition  exists  afso  in  the  big  toe. 


44     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

In  a  small  percentage  of  cases  the  second  metacarpal  and 
the  metatarsal,  besides  having  epiphyses  at  the  distal  end, 
have  additional  ones  at  the  proximal  ends. 


Fig.  38. — Showing  the  epiphysis  of  the  first  metacarpal  at  the  base  while 
the  other  metacarpals  have  their  epiphyses  at  the  distal  end. 

As  has  been  noted,  the  epiphyses  play  an  important  part  in 
injuries.  The  junction  of  the  epiphysis  and  shaft  is  relatively 
weak  and  in  injuries  of  that  region  epiphyseal  separations 
are  common.  We  seldom  have  dislocation,  as  the  joint  capsule 
is  stronger  than  the  epiphyseal  union. 


CHAPTER  IV 
FRACTURES  OF  THE  UPPER  EXTREMITIES 


CHAPTER  IV 
Fractures  of  the  Upper  Extremities 

A  FRACTURE  may  be  defined  as  a  break  in  the  bone 
texture  or  a  solution  of  continuity.  When  such  a 
condition  takes  place  we  have  a  pathological  process 
in  one  or  more  of  the  component  parts  of  the  bone,  directly 
dependent  upon  the  severity  of  the  trauma.  The  diflerent 
types  of  bone  have  already  been  described.  The  character  of 
fractures  will  vary  with  the  type  of  bone  involved,  as  trans- 
verse, obhque  and  spiral  fractures  of  the  long  Idoucs,  or  stellate 
fractures  of  the  flat  bones.  The  gravity  of  a  fracture  also  varies 
not  only  as  to  displacement,  but  also  as  to  its  position.  A  fracture 
of  a  cranial  bone  is  always  serious  whether  displaced  or  not. 
The  shaft  of  a  long  bone  msiy  not  be  perfectly  reduced,  yet  the 
function  and  cosmetic  results  will  be  good.  A  perfect  reduction 
of  a  fracture  that  extends  into  the  joint  may  end  in  hmitation 
of  motion  on  account  of  calkis  protruding  into  the  joint. 

elements  affecting  fractures 

Muscular  Tension.  Two  distinct  elements  enter  into 
every  fracture,  trauma  and  muscular  pull.  Given  a  certain 
degree  of  trauma  with  the  muscles  relaxed,  and  no  fracture 
may  ensue,  while  with  the  same  degree  of  trauma  with  the 
muscles  in  tension  a  fracture  will  occur.  This  is  of  importance, 
as  in  the  latter  condition  a  fracture  may  ensue  from  a  very 
slight  injury.  In  one  case  a  condjde  of  the  femur  was  broken 
off  by  suddenly  attempting  to  cross  the  legs.  Never  rule  out 
fracture  because  there  is  no  history  of  trauma  or  only  a  shght 
one. 

Every  bone  has  a  certain  amount  of  flexibility,  but  when 
the  muscles  are  under  tension  it  becomes  more  or  less  rigidly 

47 


48    INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

fixed,  and  a  sharp  blow  will  cause  it  to  shatter,  because  it  is 
held  so  rigidh"  that  elasticit}^  is  lacking  to  take  up  the  shock 
of  the  trauma. 

Age  and  Sex.  Besides  the  two  main  conditions  mentioned 
above,  another  factor  that  enters  into  the  production  and 
type  of  fracture  is  age. 

Up  to  the  time  of  puberty  the  growing  portions  of  the 
bones,  the  epiphj^ses,  are  but  looseh^  united  by  bands  of 
cartilage,  which  arrangement  weakens  the  bone  at  those  points. 
When  the  force  of  an  injury  centers  at  the  epiphysis  there  is 
more  apt  to  be  an  epiphyseal  separation  than  a  fracture.  As 
an  example  of  this  it  may  be  stated  that  an  epiphyseal  separa- 
tion of  the  lower  end  of  the  radius  is  extremely  common, 
while  a  fracture,  such  as  a  CoIIes's,  is  quite  rare  before  puberty. 
It  must  be  understood  that  we  are  referring  only  to  ordinary 
trauma  and  not  to  fractures  produced  by  crushing  injuries  or 
direct  heavy  bIo^^'S. 

\\'hile  the  bony  structure  before  the  age  of  puberty  is 
most  flexible,  3-et  the  presence  of  the  epiphysis,  as  just  mention- 
ed, renders  the  bone  as  a  whole  relativeh'  weak.  After  the 
epiphyses  have  united  and  up  to  forty  years  of  age  bones  are 
probabfy  at  their  strongest,  and  while  in  this  period  fractures 
are  frequent,  many  sprains  and  dislocations  are  also  seen  which 
do  not  occur  nearly  so  frequently  in  the  age  before  puberty  or  in 
old  age. 

After  fort}'  bones  begin  to  lose  their  flexibility,  and  there  is 
a  certain  absorption  of  calcium  salts,  causing  them  to  become 
brittle  and  fracture  much  more  easily.  In  this  period  disloca- 
tions are-  not  simple  but  are  generally  associated  with  fracture. 

Certain  fractures  are  met  with  in  the  old  age  period  which 
are  rarely  seen  in  the  first  two  periods.  A  fracture  of  the  neck 
of  the  femur  is  an  example  of  this.  From  a  simple  injury,  such 
as  a  fall,  it  is  extremely  rare  to  see  such  a  fracture  result 
before  fortj^  years  of  age. 

We  also  see  many  more  fractures  in  the  male  than  in  the 
female.  This  is  not  due  to  structural  weakness  of  the  bones 


FRACTURES  OF  THE  UPPER  EXTREMITIES         49 

but  is  the  result  of  habits  and  customs.  As  a  general  rule  a 
child  is  under  the  care  of  the  nurse  or  mother  up  to  live  or  six 
years,  and  accidents  resulting  in  fracture  may  occur  to  either 
sex  in  that  period.  After  that  age  and  up  to  forty  the  male 
is  engaged  in  more  active  sports  and  hazardous  occupations 
which  cause  a  great  frequency  of  fractures.  After  forty  years 
both  sexes  generally  revert  to  the  safe  way  of  living  and  the 
occurrence  of  fractures  is  again  distributed  approximately 
equally  between  the  two  sexes.  Age  and  sex  bear  a  definite 
relationship  to  fractures. 

Occupation.  There  are  certain  fractures  which  we  ma\^ 
term  occupational.  Before  the  day  of  self-starters  on  auto- 
mobiles, chauffeur's  fracture  of  the  radius  due  to  cranking 
was  not  uncommon.  This  was  a  definite  type  of  fracture  and 
could  generally  be  recognized  as  such.  It  was  interesting  to 
note  as  motors  became  more  powerful  how  the  fracture 
changed  from  a  subperiosteal  one  without  displacement  to  the 
displaced  and  comminuted  type. 

Condition  of  Soft  Tissues.  In  addition  to  determining 
the  presence  of  a  fracture  and  the  position  of  the  fragments, 
the  condition  of  the  soft  tissues  must  also  be  noted,  and  the 
presence  or  absence  of  atrophy  and  callus  determined.  A  care- 
ful study  of  the  plates  will  give  this  information. 

Just  after  a  fracture  has  occurred  the  soft  parts  surrounding 
the  fracture  will  swell  (Fig.  39)  and  this  swelling  will  persist 
for  about  one  week  after  the  fracture  has  been  immobilized. 
After  that  period  the  soft  parts  become  normal  in  size,  but  as 
the  immobilization  continues  atrophy  of  the  soft  parts  also 
will  begin  to  ensue,  due  to  disuse.  This  is  most  marked  in 
ununited  fractures.  Just  as  in  bones  this  is  a  functional  rather 
than  a  pathological  process. 

Bone  Atrophy.  When  a  fracture  is  present  the  affected 
part  is  held  immobilized  either  by  the  application  of  splints,  or 
if  not  treated  the  patient  will  hold  the  part  immobile  on  ac- 
count of  pain.  When  a  bone  is  immobilized  disuse  of  that 
part  results,  and  after  a  lapse  of  about  three  weeks  the  roent- 


50     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

genogram  will  show  a  beginning  porosity  of  the  bone,  Fig.  40. 
This  gradually  increases  according  to  the  length  of  time  of 
immobilization.  The  condition  is  known  as  atroph}^  and  is 
entirely  a  disuse  process  and  not  due  to  injurj'^  or  disease,  per 
se,  so  it  also  must  be  regarded  as  a  functional  rather  than  a 


}•  \  ^ 


}f 


Fig.  39.  Fig.  40. 

Fig.  39. — Showing  swelling  of  soft  parts  from  a  recent  iniur\',  resulting 
from  a  fracture  of  tlie  lower  third  of  the  radius. 

Fig.  40. — Old  Colles's  fracture  where  there  has  been  marked  limitation  of 
motion  with  resulting  atrophy  of  the  bones.  This  marked  degree  of 
atrophy  is  never  seen  except  with  injury  or  disease  of  long  standing. 


pathological  process.  This  can  be  readily  demonstrated  in  a 
forearm  where  the  radius  has  been  fractured  but  the  ulna  is 
intact.  At  the  end  of  five  or  six  weeks  the  ulna  will  have  be- 
come as  atrophic  as  the  broken  radius. 

Care  must  be  taken  not  to  confuse  this  general  atrophy 
with  the  localized  atrophy  present  at  the  ends  of  broken  bones. 


FRACTURES  OF  THE  UPPER  EXTREMITIES         51 

This  localized  atrophy  is  a  true  bone  absorption  and  is  the 
result  of  the  tearing  of  the  blood  vessels  with  a  resulting  death 
of  the  bone  nourished  by  the  particular  vessel  injured. 

With  increasing  age  there  is  a  gradual  absorption  of  lime 
salts,  producing  a  certain  degree  of  atrophy  of  all  the  bones. 
This  can  be  readily  recognized,  as  all  the  bones  will  be  equally 
affected,  and  the  atrophy  will  not  be  confined  to  the  injured 
bone. 

Some  ^^  riters  use  the  phrase  ''atrophy  of  quality"  when 
there  is  absorption  ol  lime  salts  and  the  bone  is  more  porous, 
and  "atrophy  of  quantity"  when  the  bone  is  smaller  in  size 
than  normal.  Atrophy  of  quantity,  is  a  very  misleading 
term,  since  it  implies  that  an  actual  reduction  in  the  size  of  the 
bone  has  taken  place,  whereas  the  difference  in  size  is  due  to 
non-development  and  not  to  shrinkage.  The  undeveloped 
femur  in  a  congenital  dislocation  illustrates  this  point. 

When  a  bone  is  immobilized,  atrophy  begins  to  show  in 
about  three  weeks  and  increases  with  the  time  of  immobiliza- 
tion. In  an  old  ununited  fracture  the  atrophy  may  be  so  exces- 
sive that  it  is  often  difficult  to  get  a  roentgenogram  which  will 
properly  demonstrate  the  bone. 

Formation  of  Callus.  It  has  already  been  mentioned 
that  the  periosteal  covering  of  the  bone  in  its  normal  state 
cannot  be  demonstrated  upon  a  roentgenogram.  When  a 
trauma  occurs  to  it,  and  especially  if  it  is  torn,  the  resulting 
reaction  will  be  the  gradual  deposition  of  hme  salts  and  the 
formation  of  new  bone.  This,  taken  in  connection  with  the 
new  bone  thrown  out  at  the  end  of  the  fragments,  wc  speak 
of  as  callus,  Fig.  41.  In  adults  this  lime  deposition  cannot  I)e 
recognized  as  such  until  nearly  four  weeks  have  elapsed,  but 
in  children  it  may  take  place  as  early  as  the  end  of  one  week. 
Up  to  that  period  the  bone  may  be  firmly  united,  yet  the  .v-ray 
will  not  show  any  calcium  salts.  During  this  prc-lime  salt 
period  we  speak  of  the  bone  and  periosteal  reaction  as  soft 
callus.  Cahus  is  then  first  seen  in  about  four  weeks,  and  under 
ordinary  conditions  reaches  its  maximum  in  six  weeks,  after 


^2     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

which  period  it  will  be  gradually  reabsorbed.  The  amount  of 
callus  depends  upon  the  severity  of  the  injury  to  the  parts 
and  upon  the  amount  of  the  displacement  of  the  fragments. 
In  the  subperiosteal  fracture  with  no  displacement  no  excess 
callus  will  form — in  fact,  sometimes  no  callus  is  seen  at  all, 
while  in  a  fracture  with  marked  displacement  there  will  be  a 


Fig.  41.  Fig.  42. 

Fig.  41. — Callus  formation  at  the  end  of  six  weeks.  Callus  as  a  rule  does 

not  show  much  before  the  fourth  week  in  adults. 
Fig.  42. — Backward  displacement  of  the  lower  end  of  the  humerus.  The 
periosteum  was  torn  loose  for  a  distance  of  two  inches  from  the  posterior 
aspect  of  the  humerus.  At  the  end  of  eight  weeks  the  space  between 
the  torn  periosteum  and  humerus  has  become  completely  filled  with 
new  bone. 


great  amount  of  callus.  The  greater  the  injury  and  the  more 
the  periosteum  is  torn  the  greater  will  be  the  new  bone 
formation. 

New  bone  formation  does  not  take  place  at  random,  but  is 
the  direct  result  of  stimulation.  In  all  cases  of  fractures  the 
stimulation  is  the  injury,  and  consequently  the  new  bone  will 
be  produced  as  far  as  the  injury  extends.  This  is  the  reason 


FRACTURES  OF  THE  UPPER  EXTREMITIES         53 

that  in  some  fractures,  particularly'  in  supracondyloid  frac- 
tures of  the  lower  end  of  the  humerus,  subperiosteal  bone  will 
be  seen  extending  upwards  a  third  or  a  half  of  the  shaft,  as  in 
such  a  fracture  the  periosteum  will  be  torn  loose  that  far, 
Fig.  42. 

If  we  take  into  consideration  soft  tissue  swelhng,  atrophy 
and  calkis  and  their  relation  to  each  other  we  can  relatively 
tell  the  age  of  the  fracture.  This  is  sometimes  of  great  impor- 
tance, as  the  following  case  will  illustrate.  A  man  of  forty-five 
entered  suit  for  $50,000  against  a  construction  company  for  a 
fracture  of  the  neck  of  the  femur  alleged  to  have  been  sustained 
while  in  the  employ  of  the  defendants.  An  .\-ray  examination 
made  two  days  after  the  injury  showed  a  fracture  of  the  neck  of 
the  femur.  At  the  trial  the  defendants  called  a  roentgenologist 
who  after  seeing  the  roentgenograms  of  the  broken  bone  was 
able  to  state  that  the  fracture  was  at  least  six  months  or  a  year 
old.  This  opinion  was  rendered  upon  the  following  data  ob- 
tained from  the  plate:  There  was  an  extreme  degree  of  atrophy 
present,  no  calhis  formation  but  partial  absorption  of  the  neck 
of  the  femur.  A  temporary  postponement  of  the  case  was 
granted.  Further  testimony  obtained  showed  that  the  patient 
had  fractured  his  hip  several  months  previously  while  in  the 
employ  of  some  concern  in  the  West  and  the  defendants  won 
the  case. 

To  summarize  briefly  the  points  in  determining  the  age  of 
the  fracture:  In  a  fresh  fracture  there  is  soft  tissue  swelling,  no 
atrophy,  no  calhis.  In  a  fracture  of  two  weeks  duration  there  is 
no  swelling,  no  atrophy,  no  callus.  In  a  fracture  of  four  weeks 
duration  there  is  slight  atrophy  of  the  soit  tissues,  atrophy  of 
bone  and  beginning  callus  formation.  In  an  old  ununited 
fracture  there  is  excessive  atrophy  of  both  soft  tissues  and  bone, 
no  callus  formation  and  the  edges  of  the  fracture  have  become 
smooth  and  slightly  eburnatcd. 

Fractures  from  Pathological  Causes.  The  above 
description  applies  only  to  traumatic  Injuries.  In  a  certain  class 
of  cases  fractures  occur  not  as  the  result  of  trauma,  but  from 


54     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

destruction  of  bone  following  some  pathological  process. 
This  is  particularly  true  in  osteomyelitis  and  in  malignant 
tumors  of  the  bone  and  in  benign  conditons  where  the  bone 
undergoes  a  rarifying  process  either  local,  as  in  bone  cysts,  or 
general,  as  in  osteomalacia  and  osteitis  deformans.  In  these 
conditions  the  fracture,  position  of  fragments  and  method  of 
repair  will  be  influenced  by  the  pathological  process  antedating 
the  fracture.  In  all  fractures  it  is  well  to  bear  in  mind  that  the 
older  the  patient  the  more  slowly  repair  takes  place  and  the 
greater  the  chance  of  non-union. 

The  duty  of  a  roentgenologist  is  not  only  to  determine  the 
presence  or  absence  of  a  fracture  but,  if  a  fracture  exists, 
whether  there  is  displacement  or  not.  By  data  obtained  from 
the  plate  he  should  be  able  to  determine  the  approximate  age 
of  the  fracture,  so  that  il  no  callus  is  present  he  can  state 
whether  it  is  too  early  for  callus,  or  that  there  is  delayed 
callus  formation  or  the  condition  of  non-union  exists. 

FRACTURES    CLASSIFIED    ACCORDING    TO    AGE 

The  foregoing  description  applies  to  fractures  in  general. 
An  attempt  will  now  be  made  to  describe  briefly  the  more 
common  fractures  that  the  roentgenologist  encounters.  These 
fractures  will  also  be  discussed  from  the  standpoint  of  age 
periods,  as  follows: 

1.  Up  to  twenty,  or  the  first  age  period. 

2.  From  twenty  to  forty,  or  the  second  age  period. 

3.  Over  forty,  or  the  third  age  period. 

Fractures  of  the  Head 

The  Skull.  Being  a  semi-hollow  sphere,  the  skull  has  a 
certain  elasticity,  and  this  in  combination  with  the  close  fit- 
ting integuments,  such  as  skin,  muscle  and  periosteum  on  the 
outside,  and  the  intracranial  contents,  gives  rise  to  variations 
in  its  fractures.  In  other  words,  displaced  fractures  are  not, 
as  a  rule,  encountered,  but  cracks  in  the  cranial  bones;  though, 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


55 


of  course,  when  there  is  a  very  severe  blow,  as  from  a  rock  or 
hammer,  or  from  a  fall  on  some  blunt  object,  there  will  be 
depressed  fractures  (Fig.  43),  which  are  easy  to  recognize. 
The  linear  fractures  (Fig.  44)  arc  often  \ery  difficult  to  detect 
and  may  be  mistaken  for  the  grooves  in  the  bones  which 
carry  the  blood  vessels.  The  importance  of  detecting  these 
linear  fractures  is  not  in  locating  the  fracture  itself,  but  because 


Fig.    43. — V   shaped    fracture   with    dei^ressioii    in   the    frontal    reiJ!;u)n. 

its  presence  indicates  a  probable  hemorrhage  beneath  it; 
and  for  this  reason,  on  account  of  the  delicate  brain  structure, 
it  is  very  necessary  to  determine  the  location  of  such  a  fracture. 
Fractures  of  the  skull  may  be  divided  into  those  ot  the 
vertex  and  those  of  the  base.  Both  types  may  come  Irom 
direct  violence  or  may  be  the  result  of  transmitted  force,  so 
that  in  such  injuries  a  careful  study  of  all  parts  ot  the  head 


56     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

should  be  made  irrespective  of  where  the  actual  trauma 
occurred.  Since  these  fractures  are  due  to  violence  thej^  may 
occur  at  any  age,  but  are  most  common  in  both  sexes  in  the 
first  age  period  and  in  males  in  the  second  age  period. 

As  linear  fractures  of  the  vertex  may  be  present  without 
a  brain  lesion  and  mav  be  overlooked,  manv  cases  of  con- 


FiG.  44. — Linear  fracture  in  the  occipital  region.  This  was  only  differ- 
entiated from  the  groove  for  a  blood  vessel  by  stereoscopic  examination. 

cussion  are  probably  fractures  of  the  vertex.  Fractures  of 
the  base  are  always  accompanied  by  grave  symptoms  and 
consequently  are  x-rayed,  hence  fracture  in  this  location  is  not 
so  often  overlooked.  Every  injury  of  the  head  should  be 
examined;  if  this  were  systematically  done  the  recorded 
percentage  of  fractures  would  be  materially  increased. 

The  important  thing  to  remember  is  that  the  majority  of 


FRACTURES  OF  THE  UPPER  EXTREMITIES         57 

fractures  of  the  skull  arc  not  important  in  themselves,  but 
are  merely  indicative  of  hemorrhage,  pressure  or  injury  to 
the  delicate  brain  structure  lying  beneath. 

Facial  Bones.  These  fractures  are  due  to  direct  violence, 
such  as  severe  blows  or  a  fall  upon  some  blunt  object.  On 
account    of    the    complexity    of  the   x-ray    shadows    in    this 


Fig.  45. — Fracture  of  tlie   malar   bone   with   hemorrhage   into  the  sinus. 

region  it  is  frequently  difllcult  to  make  the  diagnosis  from 
the  plate.  Fig.  45.  Fracture  of  the  nasal  bone  when  dis- 
placed may  be  easily  recognized.  The  zygoma  is  next  in 
frequency  and  may  also  be  recognized.  Fractures  of  the  malar 
bone  and  superior  maxilki,  unless  badly  crushed,  may  be 
overlooked.  These  fractures  are  frequently  associated  with 
hemorrhage  into  the  sinuses. 

Mandible.     Fractures    of    this    bone    are    very    rare    in 
early  childhood,  but  do  occur  in  the  hitter  part  of  the  first  age 


58     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   46. — Fracture  of  the  mandible  through  one  ol   the  molar  sockets 
followed  bv  osteomvehtis. 


Fig.  47. — Fracture  of  the  condyle  of  the  mandible  with  displacement. 


FRACTURES  OF  THE  UPPER  EXTREMITIES         59 

period.  It  is  by  far  the  most  eommon  of  all  fractures  of  the 
facial  bones  in  the  second  age  period.  In  the  white  race  at 
least  eighty  per  cent  occur  in  the  male.  In  the  colored  race 
only  about  sixty  per  cent  occur  in  the  male  and  this  is  not 
due  to  structural  weakness,  but  to  social  conditions. 

The  common  site  of  the  fracture  is  in  the  ramus  near 
the  angle  of  the  jaw,  and  the  line  of  fracture  is  transverse  or 
shghtly  oblique,  Fig.  49.  The  nearer  the  fracture  is  to  the 
angle  the  greater  the  chance  of  displacement.  Since  the  frac- 
ture generally  extends  through  one  of  the  tooth  sockets 
infection  is  common,  and  these  fractures  are  frequently 
associated  with  osteomyelitis.  Fig.  46. 

Pathological  fractures  are  quite  common  in  this  region 
as  the  result  of  infection,  cysts  or  growths.  Fractures  of  the 
condyle  and  coronoid  process  are  rare,  Figs.  47  and  48. 

Fractures  of  the  spine  will  be  discussed  separately  in  the 
chapter  on  the  spine.  (See  Chapter  XII.) 

Fractures  0/  the   Upper  Extremities 

Clavicle.     Fractures  of  the  clavicle  may  be  di\ided  into: 

1.  Fractures  of  the  inner  third. 

2.  Fractures  of  the  middle  third. 

3.  Fractures  of  the  outer  third. 

Fractures  of  the  inner  third  are  relati\ely  infrequent 
and  seem  to  occur  by  direct  trauma,  such  as  a  severe  blow. 
Fractures  of  the  middle  third,  especially  at  the  junction  with 
the  outer  third,  are  the  most  common  of  all.  Fractures  of  the 
outer  third,  especially  near  the  acromial  end,  are  also  quite 
frequent. 

In  fracture  of  the  inner  third  the  few  cases  observed  by 
the  writers  were  all  in  the  second  age  period.  Fractures  of 
the  middle  third  are  most  common  in  childhood  and  decrease 
in  frequency  with  the  approach  of  old  age.  This  is  prol^ably 
due  not  to  structural  weakness,  but  to  the  fact  that  the  dan- 
ger of   trauma  decreases  w^ith  age.    In   the   first  age  period 


6o     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  48. — Fracture  of  the  coronoid  process  of  the  mandible.  The  frag- 
ment extends  down  to  the  third  molar. 


Fig.  49. — Obhque  fracture  of  the  mandible,  not  complete. 


FRACTURES  OF  THE  UPPER  EXTREMITIES        6i 

these  fractures  of  the  middle  third  may  be  of  the  green-stick 
variety  (Fig.  50)  with  marked  bowing  or  angulation,  or  com- 
plete fractures  with  displacement.  They  may  be  either  trans- 
verse or  obhque.  In  the  transverse  type  in  children  reduction 
seems  to  be  more  difficult  than  in  the  adult  and  the  fragments 
frequently  have  to  be  wired.  These  fractures  may  result 
from  very  slight  trauma  and  may  be  unrecognized.  In  one 
case  of  a  child  of  two  years  a  diagnosis  of  sarcoma  was  made. 
The  A'-ray  examination  showed  a  fracture,  and  the  hard  mass 
present  was  callus  formation.  In  the  second  age  period  the 
middle  third  is   frequently  broken  and   is  generally  oblique 


Fig.  50. — Green-stick  fracture  ol  the  outer  third  of  the  clavicle  in  a  child. 

with  the  outer  fragment  displaced  downward.  In  the  third 
age  period  the  middle  third  is  less  frequently  broken  than  the 
outer  third.  In  the  young  fracture  of  the  outer  third  is  common, 
and  the  fragment  is  generally  displaced  downwards,  Fig.  51. 
In  the  second  and  third  age  periods  there  is  one  fracture  of 
the  outer  third  that  deserves  especial  attention,  since  the 
clinical  diagnosis  of  this  is  often  wrong.  In  these  periods, 
dislocation  upward  of  the  clavicle  at  its  acromial  end  is  quite 
common.  In  a  number  of  cases,  however,  instead  of  a  true 
dislocation  taking  place,  the  tip  of  the  clavicle  is  fractured. 
Fig.  52.  It  remains  in  situ,  but  the  clavicle  rides  up  and  the 
prominent  end  that  is  uppermost  is  often  mistaken  for  the 


62     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

end  of  the  clavicle  when  in  reahty  it  is  the  fractured  end  of  the 
shaft. 

Scapula.  Fractures  ot  the  scapula,  excepting theacromion, 
are  relatively  uncommon  and  many  of  them,  especially 
ot  the  body,  are  not  recognized.  They  may  be  divided  into 
fractures  of  the  body,  spine,  glenoid  fossa,  coracoid  lower 
angle,  and  acromion. 

Fractures  of  the  bod}'  (Fig-  53)  generally  occur  in  the 
subspinous  fossa  starting  just  below  the  glenoid  fossa,  and  are 


Fig.  5 1 . — Fracture  of  the  outer  third  of  the  clavicle  with  shght  displacement. 


often  incomplete.  Fractures  of  the  spine  ( Fig.  54)  are  uncom- 
mon unless  associated  with  fractures  of  the  body.  Fractures  of 
the  glenoid  (Fig.  55)  are  quite  rare,  and  generall}'  the  lower 
third  is  involved,  though  the  writers  have  seen  one  case  where 
the  glenoid  was  separated  irom  the  body.  Fractures  of  the 
coracoid  (Fig.  56)  are  also  uncommon;  the  tip  is  sometimes 
pulled  off  by  muscular  violence.  The  lower  angle  is  occasionally 
broken  off  and  may  be  displaced.  Care  must  be  taken  not  to 
confuse  the  epiphysis  of  the  angle  for  a  fracture.   Fracture  of 


FRACTURES  OF  THE  UPPER  EXTREMITIES         63 


Fig.  52. — Fracture  of  the  extreme  tip  of  the  clavicle,  tlie  small  fragment 
remaining  in  situ  while  the  shaft  of  the  clavicle  has  ridden  up,  simulat- 
ing a  dislocation. 


^yg 


Fig.  53. — Fracture   of  the   body   of  the   scapula    with    the   glenoid   dis- 
placed inward. 


64    INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  acromion  (Fig.  57)  is  most  common  and  the  outer  tip 
is  frequently  pulled  off  instead  of  an  acromio-clavicular  dis- 
location. Scapular  fractures  are  uncommon  in  the  first  age 
period  and   most   frequent  in  the  second  age  period. 

Hu-MERUS.  In  the  first  age  period  we  have  the  epiphysis 
present,  and  this  relatively  weakens  that  portion  of  the  arm, 
3'et  separation  is  very  uncommon,  Fig.  58.  The  writers  have 


.S0^ 


Fig.  54. — Fracture  at  the  base  of  the  spine  of  the  scapula. 

had  only  two  such  cases.  In  these  cases  the  head  remained  in 
the  glenoid  fossa  but  rotated  slightly  allowing  the  shaft  to 
slip  shghtly  upward  and  outward.  In  young  infants  this 
injury  may  occur  more  often  than  is  supposed,  but  since 
no  ossification  centers  are  present  it  cannot  be  demonstrated, 
as  cartilage  does  not  cast  a  shadow  upon  the  x-ray  plate. 
Upper  End.  The  most  common  fracture  in  this  age 
period  is  in  the  upper  third  of  the  shaft  or  in  the  surgical 


^P 

^ 

^ 

^^jf^l 

^B 

Vi 

^I^^B 

''>'-i 

^ 

J 


■■A 

'-5  '^ 

:^  'o 


U-, 


66     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  57. — Fracture  of  the  tip  of  the  acromial  process  with  displacement. 


Fig.  58. — Epiphyseal  separation  of  the  upper  end  of  the  humerus.  Note 
the  rotation  of  the  head  with  ridmo;  up  of  the  shaft. 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


67 


neck,  Fig.  59.  These  are  generally  transverse,  and  the  upper 
fragment  is  displaced  outward.  Fracture  of  the  greater 
tuberosity  is  uncommon. 

In  the  second  and  third  age  periods  fractures  of  the  ana- 
tomical neck  may  occur.  In  the  experience  of  the  writers  this  is 
a  very  rare  fracture;  while  the  clinical  diagnosis  of  this  fracture 


Fig.  59. — Fracture  of  the  surgical  neck  of  the  humerus  in  a  patient  over 
fifty,  associated  with  a  fracture  of  the  greater  tuberosity. 

is  made,  the  diagnosis  is  seldom  borne  out  by  the  .v-ray  findings. 
Only  two  such  cases  have  come  under  our  observation. 

Fracture  of  the  surgical  neck  of  the  humerus  is  the  most 
common,  most  frequent  after  the  age  of  twenty.  This  fracture 
may  be  transverse,  slightly  oblique  or  impacted.  Displacement 
varies  according  to  the  nature  and  severity  of  the  trauma.  It 


68     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


may  be  associated  with  fracture  of  the  greater  tuberosity  or 
with  dislocation  of  the  head  of  the  humerus. 

In  the  second  age  period  the  fracture  is  confined  to  the 
surgical  neck,  and  is  seldom  associated  with  fracture  of  the 
greater  tuberosity  or  dislocation  of  the  head.  The  shaft,  when 
displaced,  as  is  also  the  case  in  the  first  age  period,  is  generally 

pushed    to  the  inner   side, 
Fig.  60. 

In  the  third  age  period 
this  is  by  far  the  most  com- 
mon of  all  fractures  of  the 
humerus,  and  is  frequently 
associated  with  fractures  of 
the  greater  tuberosity  (Fig. 
61)  or  dislocation  of  the 
head.  The  capsule  is  often 
badly  torn,  so  that  the  end 
of  the  shaft  rides  up  into  the 
glenoid  fossa  and  displaces 
the  head  outward.  Fig.  62. 
Where  the  head  is  not  dis- 
located it  rotates  slightly 
outward,  so  that  the  frac- 
tured surface  points  out- 
w^ard.  When  the  fracture 
unites  in  this  position  the 
arm  can  only  be  raised  to  a 
right  angle.  This  is  due  to 
the  fact  that  at  the  time  of 
union  the  head  is  in  a  position  of  partial  rotation  and  when 
the  arm  is  raised  to  a  right  angle  the  head,  on  account  of  its 
abnormal  position,  is  in  complete  rotation.  Occasionally  frac- 
ture of  the  surgical  neck  is  accompanied  by  a  "T"  fracture 
through  the  head,  and  then  the  internal  portion  of  the  head  is 
dislocated,  lying  generally  beneath  the  coracoid  or  in  the  axilla. 
Fracture  of  the  tuberosity  alone  is  quite  common  and  is 


Fig.  60. — Showing  the  outward  dis- 
placement of  the  head  of  the 
humerus  in  a  fracture  near  the 
surgical  neck. 


FRACTURES  OF  THE  UPPER  EXTREMITIES        69 

often  unrecognized,  as  there  may  be  no  displacement  of  the 
fragment,  Fig.  63.  It  is  only  after  there  is  marked  limitation  of 
motion  that  something  more  serious  than  a  bruise  is  suspected. 
Occasionally  the  attachments  of  the  scapular  muscles  will  be 
torn  loose  with  a  small  bony  fragment.  This  small  fragment 
will  be  just  external  to  the  greater  tuberosity.  Care  must  be 


Fig.   61. — Old  fracture  of  the  greater  tuberosity  and  surgical   neck  of 
the  humerus  with  atrophy  from  disuse. 

exercised  not  to  confuse  this  condition  with  subdeltoid  bursitis 
with  a  calcium  deposit  in  the  wall  of  the  bursa.  Sometimes 
it  is  impossible  to  differentiate  the  two  conditions.  The  follow- 
ing case  will  ilkistrate  this  point. 

A  man,  aged  forty,  fell  striking  his  left  shoulder.  Two  hours 
after  the  injury  swelling  became  pronounced  and  was  accom- 
panied by  severe  pain  and  limitation  of  motion.  The  .v-ray 
disclosed  what  was  taken  to  be  a  small  fragment  of  bone  torn 


70    INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


loose  from  the  tuberosity.  The  arm  was  immobihzed  but  there 
was  no  relief  from  pain.  There  had  been  no  past  history  of  any 
discomfort  in  or  injury  to  that  shoulder.  It  was  finally  decided 

that  the  apparent  frag- 
ment of  bone  was  in  reality 
a  deposit  of  calcium  in  the 
bursa.  Operation  confirmed 
this  and  with  removal  of 
the  bursa  the  patient  made 
a  complete  recovery. 

W  hile  every  injury,  es- 
peciallv  in  elderly  indi- 
\iduals,  should  be  viewed 
with  suspicion  as  to  frac- 
ture, it  must  be  borne  in 
mind  that  there  is  always 
present  a  quiescent  low- 
grade  arthritic  condition. 
This  may  never  have 
troubled  the  patient,  yet 
an  injury  to  the  part  may 
cause  this  arthritis  to  flare 
up  and  produce  such  acute 
pain  in  the  joint  that 
a  fracture  will  be  sus- 
pected. 

Shaft.  Fractures  of  the  shaft  are  common  and  may  occur 
anywhere  between  the  surgical  neck  and  the  supracondyloid 
ridge,  though  fracture  of  the  middle  portion  is  most  frequent. 
There  is  no  definite  displacement,  as  this  varies  according  to  the 
nature  and  severity  of  the  trauma.  In  the  first  age  period 
(Fig.  65)  green-stick  and  oblique  fractures  are  more  frequent, 
while  in  the  second  and  third  age  periods,  transverse  and 
comminuted  fractures  are  more  common.  Fig.  66.  The  one 
interesting  thing  in  fractures  of  the  shaft  is  that  non-union  is 
quite   frequent,  due  partly  to  the  displacement  of  the  frag- 


FiG.  62. — Fracture  ut  the  surgical  neck 
of  the  humerus  with  the  end  of  the 
shaft  in  the  glenoid  fossa  and  the 
head  displaced  outward. 


FRACTURES  OF  THE  UPPER  EXTRExMITIES         -i 

ments    and   partly    to    muscle   or   fasciae    lying   between  the 
fragments. 

Lower  End.     Fractures  of  the  lower  end  of  the  humerus 


Fig.  63. — Old  fracture  of  the  greater  tuberosity  of  the  humerus,  not  recog- 
nized at  the  tune  of  iniury. 


below  the  supracondyloid  ridges  are  the  most  common  of  all. 
They  may  be  divided  into: 

1.  Supracondyloid  fractures  (epiphyseal  in  the  young). 

2.  Fracture  of  the  external  condyle. 

3.  Fractures  of  the  internal  condyle. 

4.  Fractures  of  the  internal  epicondyle. 

5.  Fractures  of  the  external  epicondyle. 

6.  Fractures  of  the  capitelhim  and  trochlea. 

The  supracondyloid  fractures  may  be  transverse  or  oblique, 
and  when  close  to  the  condyles  may  extend  through  the  olecranon 


-2     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


fossa,  and  there  is  often 
present  a  "T"  fracture  ex- 
tending into  the  joint.  The 
lower  fragment  may  be  dis- 
placed laterally  or  posteriorly 
according  to  the  line  of  the 
fracture.  In  the  first  age 
period  the  supracondyloid 
fracture  generally  involves 
the  epiphyseal  line,  and  in 
the  very  young  the  fragment 
is  usually  displaced  back- 
wards and  slightly  to  the 
Fig,  64. — Epiphyseal  separation  of  the  inner  sides,  Fig.  64.  It  is  a 
lowerendofthe  humerus.  The  joint  yerv  difficult  fracture  to  re- 
is  carried  back  with  the  fragment.      ^j^^^^^_  j^^   internal  displace- 


Fig.  65. — Green-stick  fracture  of  Fig.     66. — Spiral     fracture     of    the 

the  humerus  in  an  infant  with  humerus.     Such     fractures    are 

no    displacement.    Just   dis-  more  commonly  seen  in  the  first 

cernible.  age  period. 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


73 


ment  of  the  lower  fragment  can  be  corrected  and  held.  The 
posterior  displacement  can  be  corrected,  but  generally  can- 
not be  held,  Fig.  67.  When  this  fracture  occurs  the  periosteum 
on  the  posterior  surface  is  torn  loose  for  some  distance 
along  the  shaft.  In  such  cases  where  reduction  cannot  be 
obtained  the  fragment  may  be  left  in  this  position  and  the 
displaced  periosteum  will  throw  down  a  strong  bony  bridge. 
When  this  has  taken  place  the  lower  end  of  the  shaft  will  be 
anterior  and  will  prevent  flexion.  An  open  operation  in  chisel- 


FiG.  67. — An  attempted  reduction  of  a  supracondylar  fracture  of  the 
lower  end  of  the  humerus.  This  was  reduced  under  fluoroscope,  but 
the  fragment  could  not  be  held  in  the  plaster  cast  and  reverted  to  the 
original  displacement. 

ing  off  this  fragment  will  give  a  perfectly  functioning  elbow. 
This  fracture  is  often  diagnosed  as  dislocation  of  the  elbow. 

Fractures  of  the  cpicondyles  in  children  often  cannot  be 
demonstrated  on  account  of  their  being  entirely  cartilag- 
inous. The  internal  epicondyle  is  most  frequently  fractured. 
The  writers  have  never  seen  a  fracture  of  the  external  epi- 
condyle. Fractures  of  the  condyle  are  most  common  in  this  age 
period,  and  fracture  of  the  external  condyle  is  the  more  common 


74     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

of  the  two.  They  may  or  may  not  be  displaced,  varying  accord- 
ing to  the  nature  and  severity  of  the  trauma.  In  the  second 
and  third  age  periods  the  supracondyloid  fracture  generally 
takes  place  just  where  the  shaft  expands  to  form  the  condylar 
portion  of  the  lower  end.  These  fractures  are  oblique,  and  the 
fragment  may  be  displaced  forward  or  backward  according  to 
the  nature  of  the  injury.  Fractures  of  the  condyles  (Fig.  68) 
are  more  common  in  the  second  age  period  than  in  the  third. 
The  supracondyloid  fracture  in  the  second  age  may  be  accom- 


FiG.  68. — Fracture  of  the  external  condyle  of  the  lower  end  of  the  humerus. 
The  fracture  almost  extends  into  the  fossa. 

panied  by  a  "T"  fracture  into  the  joint.  The  fragments  may 
be  more  or  less  displaced. 

Fractures  of  the  capitellum  and  trochlea  are  quite  rare 
except  where  there  is  a  crushing  injury  of  the  joint. 

In  injuries  of  the  lower  end  of  the  humerus  in  young 
children  care  must  be  exercised  in  making  a  diagnosis  of  "  no 
fracture."  We  must  bear  in  mind  that  a  great  portion  of  the 
joint  is  cartilaginous  and  that  a  fragment  of  cartilage  may  be 
broken  off  and  yet  not  be  demonstrable  by  the  x-ray.  In  such 
cases  it  has  always  been-  the  custom  of  the  writers  to  return 
a  diagnosis  stating  that  no  fracture  can  be  demonstrated. 

Forearm.  Upper  End.  Fractures  of  the  olecranon  may 
occur  at  any  age,  but  seem  to  be  most  common  in  early  adult 


FRACTURES  OF  THE  UPPER  EXTREMITIES         -5 

and  middle  life,  though  occasionally  in  the  young  the  epiphyses 
may  be  torn  loose.  Besides  trauma,  muscular  pull  plays  an 
important  part  in  this  fracture,  the  writers  having  seen  such  an 
instance  from  throwing  a  base  ball. 

The  fracture  may  take  place  in  any  portion  of  the  coronoid 
fossa  and  is  very  seldom  comminuted.  The  position  of  the  frag- 
ment depends  entirely  on  whether  the  triceps  attachments 
are  torn  loose.  If  attachments  are  intact  there  will  be  no 
separation  (Fig.  69),  but  if  torn,  the  fragments  may  be  widely 


Fig.  69.  Fig.   -o. 

Fig.  69. — Fracture  of  the  olecranon  process.  There  is  no  displacement  as 

the  fascia  has  not  been  torn. 

Fig.  70. — Fracture  of  the  olecranon   process  where  the  fascia  has  been 

torn  which  has  allowed  the  fragment  to  separate  and  rotate. 

separated,  Fig.  70.  It  is  interesting  to  note  that  the  chance  of 
fibrous  instead  of  bony  union  increases  with  the  nearness  of 
the  fracture  to  the  tip  of  the  olecranon;  and,  conversely,  as  the 
fracture  approaches  the  shaft,  bony  union  generally  takes  place. 
A  fracture  of  the  coronoid  process  (Fig.  ^i)  is  generally 
associated  with  backward  dislocation  of  the  ulna.  It  is  very 
uncommon  as  a  simple  fracture.  The  line  of  fracture  is  roughly 
parallel  or  slightly  oblique  to  the  long  axis  of  the  shaft.  \\  hile 


-6     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


the  writers  have  seen  such  cases  they  are  extremely  uncommon, 
and  in  none  of  the  cases  observed  was  there  any  displacement 
of  the  fragment. 

Fractures  of  the  head  of  the  radius  are  frequent  and  may 
var}^  from  cracks  to  comminuted  fractures  with  displacement 


Fig.  71.  Fig.  72. 

Fig.  71. — Fracture  of  the  coronoid  process  and  the  head  of  the  radius  with 

dislocation  of  the  joint  not  completely  reduced. 
Fig.  72. — A  small  fragment  of  the  head  of  the  radius  broken  off.  The  small 
calcified  areas  above  this  fragment  are  in  the  Hgaments  and  are  probably 
due  to  calcification  of  small  hemorrhages.  Fracture  is  six  months  old. 

of  the  fragments.  This  fracture  is  common  in  early  adult  life 
and  old  age.  It  is  very  uncommon  in  the  young  and  the  writers 
have  never  seen  a  case  of  epiphyseal  separation. 

Fractures  of  the  radial  head,  unless  displaced,  are  often 
overlooked.  It  is  the  wTiters'  experience  that  careful  examina- 
tion of  the  radial  head  in  injuries  of  the  elbow  w  ill  show  frac- 
tures without  displacement  to  be  much  more  frequent  than  is 
commonly    supposed,    and    that    these    fissure    fractures    are 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


//' 


seldom  recognized  at  first.  In  fact  the  patient  does  not  consult 
a  surgeon  at  first,  thinking  he  has  only  a  bruise;  but  with  no 
amelioration  of  discomfort,  at  the  end  of  a  week  or  ten  days, 
he  seeks  professional  advice  and  x-ray  examination  shows  the 
fracture.  The  writers  saw  four  such  cases  in  one  afternoon,  and 


m 


Fig.  73-  E'G.  74. 

Fig.  73. — Fracture  of  the  Iicad  of  the  radius  with  part  of  the  head  displaced. 
Fig.  74.- — Fracture  of  the  neck  of  the  radius  with  marked  anterior  dis- 
placement. 


all  had  sustained  their  injuries  a  week  or  ten  da\  s  previously. 
The  fracture  may  be  confined  to  just  a  part  ol  the  outer  edge 
of  the  head  (Fig.  72);  it  may  extend  into  the  shaft;  or  it  may 
be  comminuted  (Fig.  73),  and  divide  the  head  into  several 
fragments.  When  there  is  no  displacement  and  the  fracture  is 
healed,  a  large  percentage  of  the  cases  do  not  get  complete 
extension  of  the  arm.  In  the  comminuted  type,  where  one  or 
more  fragments  are  displaced,  non-union  will  sometimes  take 
place,  and  in  that  case  the  fragment  acts  as  a  foreign  body  and 


^8     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


has  to  be  removed.  Sometimes  when  displaced  they  will  unite 
with  excess  callus  and  interfere  with  rotation. 

Fractures  of  the  neck  of  the  radius   (Fig.   74)   are  much 
less  frequent  than  those  of  the  head.  The  line  of  fracture  is 


'# 


Fig.  7S-  Fig.  -6. 

Fig.  75. — Lateral  view  showing  fracture  of  the  upper  third  of  the  uhia  with 

anterior  dislocation  of  the  head  of  the  radius. 
Fig.  76. — Same    condition    as   that   shown   in   Fig.  75   from  an  antero- 
posterior position. 

generally  oblique,  and  there  is  usually  displacement.  It  is 
often  very  difficult  to  reduce  and  hold  these  fragments  in 
place.  Displacement  with  non-union  is  fairly  frequent. 

Fracture  of  the  ulna  (Figs.  75  and  76)  alone  is  generally 
seen   in   the   upper  third  just  behind  the  coronoid  fossa  and 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


is  frequently  associated  with  dislocation  of  the  head  of  the 
radius  forward,  Fig.  77. 

Shaft.     Fractures  of  the  shaft  of  both  bones  of  the  forearm 
are  probably  next  in  frequency  to  Colles's  fracture,  and  may 


m 


Fig.  77.  Fig.  78. 

Fig.  77. — Old  fracture  of  the  upper  third  of  the  ulna  with  forward  dislo- 
cation of  the  radius.  The  radius  has  shpped  well  up  on  the  head  of  the 
humerus,  due  to  the  shortening  of  the  ulna  from  absorption. 
Fig.  78. — Green-stick  fracture  of  radius  and  ulna  showing  angulation  but 

no  displacement. 

occur  at  any  age  period.  Fractures  of  the  middle  and  lower 
third  are  the  common  situations,  and  are  relatively  infrequent 
in  the  upper  third.  Unless  the  fractures  are  of  the  green- 
stick  (Fig.  78)  or  subperiosteal  variet}'^  invariably  there  is  dis- 
placement with  more  or  less  over-riding  of  the  fragments,  Fig. 
79.  This  displacement  may  be  so  excessive  that  union  will  not 
take  place,  or  if  it  takes  place  the  excess  callus  may  actually 


8o     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


produce  a  bony  synostosis  and  rotation  will  be  lost.  In  children 
this  fracture  is  often  incomplete  and  of  the  greenstick  variety. 

Lower  End.  Fractures  in  this  region  may  be  ad\antage- 
ously  studied  according  to  the  three  age  periods. 

In  the  first  period  the  most  important  part  of  the  lower 


Fig.  -^g.  Fig.  8o. 

Fig.  79. — Fracture  and  displacement  of  radius  and  uhia. 
Fig.  80. — Backward  dislocation  of  the  epiphysis  of  the  lower  end  of  the 
radius.  The  joint  is  carried  back  with  the  epiphysis. 

end  of  the  radius  is  the  epiphysis.  Its  union  with  the  shaft  is 
relatively  weak  when  compared  with  the  shaft  of  the  bone, 
and  trauma  localized  at  that  point  will  frequently  displace 
it  (Fig.  80)  instead  of  breaking  the  bone.  When  this  takes  place 
the  condition  is  much  more  serious  than  that  obtaining  with 
an   ordinary    fracture.    In    a   fracture   ^^•ith    faulty   reduction 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


the  end  result  is  a  deformity;  with  a  displaced  epiphysis  not 
only  the  deformity  results  but,  what  is  infinitely  more  impor- 
tant, the  growing  portion  of  the  bone  is  destroyed.  If  the 
epiphyseal  separation  is  not  reduced,  the  deformity  steadily 
increases  as  the  ulna  continues  to  grow,  while  the  end  of  the 
radius  remains  stationary.  This 
will  result  in  a  marked  deflection 
of  the  hand  to  the  radial  side, 
continuing  to  increase  until  the 
ulna  has  reached  its  full  growth. 
This  epiphyseal  separation  of 
the  radius  is  sometimes  accom- 
panied by  a  chipping  off  of  a 
small  fragment  of  bone  from  the 
ulnar  side  of  the  diaphysis  of  the 
radius.  Fig.  8i.  Fracture  of  the 
styloid  of  the  ulna,  as  in  CoIIes's 
fracture,  is  also  occasionally  as- 
sociated with  this  separation ;  but 
the  writers  have  never  seen  the 
ulnar  epiphysis  torn  off.  Occa- 
sionally after  a  trauma  one  will 
find  a  swollen  wrist  and  limita- 
tion of  motion;  the  x-ray  exami- 
nation, however,  will  disclose  no 
separation,  but  the  epiphyseal 
line  seems  to  be  a  trifle  wider  and 
more  irregular  than  is  normally 

seen.  This  swelling  and  tenderness  may  persist  for  several 
weeks;  and  in  one  case  under  the  writers'  observation,  without 
any  additional  injury  the  epiphysis  became  slightly  displaced, 
though  it  was  in  normal  position  just  after  the  injury.  This 
gives  rise  to  the  belief  that  following  trauma  the  epiphysis 
may  partially  slip  off  and  then  snap  back  into  position  again. 
When  such  a  condition  is  suspected  the  arm  should  be  placed 
in  splints  and  treated  as  an  ordinary  fracture. 


Fig.  8i. — Epiphyseal  separation 
of  the  lower  end  of  the  radius 
with  a  small  fragment  torn 
off  from  the  radius. 


82     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

\\'hen  the  patient  falls  upon  the  palm  of  the  hand  the 
epiphysis  is  dislocated  posteriorly;  if  the  hand  is  flexed  and  the 
patient  falls  upon  the  dorsum  then  the  dislocation  is  anterior, 
but  this  is  extremely  rare.  If  the  trauma  is  sufiicient  to  produce 
fracture  and  the  epiphysis   does   not  yield,   then  the  radius 


Fig.  82.  Fig.  83. 

Fig.  82.— Fracture  of  both  bones  of  the  forearm,  just  below  the  point  where 

a  CoIIes's  fracture  would  occur  in  the  third  age  period. 
Fig.  83. — Fracture  in  the  second  age  period  where  both  bones  of  the  fore- 
arm are  broken,  resulting  from  a  fall  which  would  have  produced  a 
CoIIes's  fracture  if  the  patient  had  been  older. 

fractures  an  inch  to  an  inch  and  a  half  below  the  epiphj^sis 
(Fig.  82)  and  is  frequently  associated  with  a  fracture  of  the 
idna  at  the  same  point.  \\  hen  this  condition  takes  place  the 
fragments  generally  override,  and  on  accmmt  of  the  pronator 
muscles  it  is  often  impossible  to  reduce  them  without  an  open 
operation. 

Occasionalh'  the  ulna  alone  will  be  fractured  in  this  same 
region.  In  this  age  period  green-stick  and  subperiosteal  frac- 
tures are  frequent.  On  account  of  the  flexibility'  of  the  bones  in 


FRACTURES  OF  THE  UPPER  EXTREMITIES         83 

this  period  it  is  unusual  to  see  comminuted  fractures  resulting 
from  simple  injuries. 

In  the  next  age  period  the  epiphyses  of  the  bones  have 
united,  and  trauma  in  this  region  will  cause  a  fracture  of  the 
radius  or  ulna  or  both  about  an  inch  and  a  half  below  the  joint, 


Fig.  84. 


Fig. 


Fig.  84. — CoIIes's   fracture   with    marked   displacement   backward   of  the 

lower  fragment  carrying  the  joint  with  it. 

Fig.  85. — CoIIes's  fracture  with  anterior  displacement  of  the  lower  fragment 

due  to  falling  on  the  dorsal  instead  of  the  anterior  surface  of  the  hand. 


and    as    in    the    first    age    period    we    maj^    ha\e    the   same 
deformities.  Fig.  83. 

During  this  period  CoIIes's  fracture  is  unusual.  In  repeated 
series  of  consecutive  CoIIes's  fractures  resulting  from  falls  we 
have  found  that  only  from   i  to  2  per  cent  occur  in  this  age 


84     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

period.   From  direct  blows,  such  as  cranking  a  car,  we  see 
CoIIes's  fractures;  but  this  type  we  may  term  occupational. 

In  the  last  age  period  the  CoIIes's  fracture  predominates. 
A  CoIIes's  fracture  is  essentially  a  fracture  of  the  middle-aged 
and  old.  Repeated  series  of  this  fracture  show  that  from  98  to 
99  per  cent  are  above  the  age  of  forty.  This  is  no  doubt  due  to 
what  may  be  termed  senile  changes  in  the  bone,  i.e.,  loss  of 


Fig.  86. 


Fig.  8' 


Fig.  86. — An  old  CoIIes's  fracture  with  backward  displacement,  the  usual 

position  of  the  fragment. 

Fig.  87. — Impacted  CoIIes's  fracture  with  no  displacement.  This  t\-pe  of 

fracture  is  frequently  mistaken  for  a  sprain. 


flexibility  and  absorption  of  calcium  salts,  thus  causing  the 
bone  to  become  brittle. 

This  fracture  is  through  the  cancellous  portion  of  the  end  of 
the  radius;  it  extends  across  the  bone  about  three  quarters  of  an 
inch  below  the  joint,  and  is  generally  associated  with  a  fracture 
of  the  styloid  of  the  ulna.  In  the  writers'  series  of  cases  the  sty- 


FRACTURES  OF  THE  UPPER  EXTREMITIES         85 


loid  of  the  ulna  was  broken  in  from 

This  fracture  may  vary  from 
simple  to  comminuted,  and,  as 
in  epiphyseal  separations,  the 
lower  fragment  may  be  displaced 
posteriorly  (Fig.  84)  or  anteriorly 
according  to  whether  the  fall  was 
on  the  palmar  or  dorsal  surface 
of  the  hand  (Fig.  85),  the  former 
being  by  far  the  most  common. 
The  roentgenologist  probably 
sees  more  old  CoIIes's  fractiu-es 
than  any  other  type  of  fracture, 
and  this  is  because  such  a  fracture 
if  improperly  set  will  give  more 
trouble  than  any  other.  In  cases 
w^here  bad  end  results  are  ob- 
tained it  is  due  to  one  of  the 
following  three  causes: 

I.  Posterior  dislocations, 
W'here  the  fragment  has  not  been 
reduced.  Fig.  86. 

2.  Impaction,  where  the  shaft 
is  driven  into  the  fragment  with- 
out any  displacement  at  all.  In 
such  cases  on  account  of  the  good 
alignment  of  the  bone  and  lack  of 
displacement  the  fracture  is  fre- 
quently dressed  Nxithoiit  rechic- 
tion.  Fig.  87. 

3.  Angulation,  where  the 
fragment  has  not  been  dislocated 
but  has  turned  upon  its  axis,  so 
that  while  there  is  no  displace- 
ment, yet  the  long  axis  of  the  w 
correspond  to  the  long  axis  of  the 


60  to  70  per  cent  of  the  cases. 


Fig.  88.— Old  CoHcs's  fracture 
where  there  is  angulation 
without  displacement.  Note 
the  divergence  of  the  axes 
of  the  shaft  and  fragment. 

rist  and   fragment  does  not 
radius.  Fig.  88. 


86     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

The  vast  majority  of  impacted  fractures  result  in  painful  and 
partially  stiff  wrists.  If  such  a  fracture  is  examined  three  weeks 
after  reduction  there  will  be  found  absorption  of  the  ends  of  the 
fragments,  and  with  the  muscular  tension  these  fragments  are 
pulled  together  and  shortening  is  produced.  If,  however, 
the  impaction  is  broken  up,  then  the  fragments  are  separated 
and  the  consequent  hemorrhage  taking  place  between  them 
keeps  the  fragments  apart,  so  that  when  union  takes  place 


Fig.  89.  Fig.  90. 

Fig.  89. — A  Barton's  fracture  which  follows  approximately  the  epiphyseal 

line  if  that  were  present.  A  very  rare  fracture. 
Fig.  90. — An  old  fracture  of  the  styloid  of  the  radius.  Note  the  marked 

atrophy  from  disuse. 


there  is  no  shortening.  It  is  a  safe  rule  to  follow  that  where  the 
condition  of  the  patient  permits,  every  impacted  CoIIes's 
fracture  should  be  broken  up.  If  this  is  done  the  end  results  will 
be  infinitely  better. 

The  important  point  to  remember  is  that  it  is  the  anterior 
or  posterior  dislocations  which  produce  the  more  or  less 
painful  and  partial  limitations  of  movements,  while  lateral 


FRACTURES  OF  THE  UPPER  EXTREMITIES    8- 

displacement  gives  an  enlarged  wrist,  but  it  is  not  painful 
nor  does  it  limit  motion. 

In  middle  and  old  age  every  injury  to  the  wrist  must  be 
looked  upon  as  a  probable  fracture,  as  the  so-called  sprains  in 
the  third  age  period  are  very  rare.  This  is  particularly  true 
of  those  with  impaction,  as  there  is  no  displacement  and  on 
account  of  lack  of  deformity  they  are  frequently  overlooked 
unless  A-rayed. 

Besides  the  fractures  already  mentioned  there  are  two  others 
of  the  low^er  end  of  the  radius,  Barton's  fracture  and  fracture  of 
the  styloid  of  the  radius.  Barton's  fracture  (Fig.  89)  seen  only  in 
the  adult,  is  a  transverse  fracture  of  the  radius  just  below  the 
joint,  that  is,  between  the  site  of  a  CoIIes's  fracture  and  the 
articulating  surface  of  the  radius.  This  fracture  takes  place 
at  the  site  of  what  would  be  the  epiphyseal  line  if  it  were 
present.  There  is  seldom  any  displacement. 

Barton  describes  this  as  a  common  fracture,  but  in  the 
writers'  experience  in  over  ten  thousand  fractures  around  the 
wrist  joint,  it  was  found  to  be  very  rare. 

Fractures  of  the  styloid  of  the  radius  (Fig.  90)  are  quite 
common  and  vary  in  position  from  the  tip  of  the  styloid  to 
an  oblique  fracture  through  the  joint  surface,  involving  a  third 
of  the  radial  end.  If  the  fracture  is  simple  it  is  seldom  displaced. 
It  is  frequently  associated  with  a  CoIIes's  fracture,  and  then  it 
is  often  displaced.  Ununited  fractures  in  this  region  do  not 
occur. 

Wrist.  Fracture  of  the  scaphoid  (Fig.  91)  is  the  most 
common  of  all  carpal  fractures.  It  may  occur  alone,  but  is 
frequently  associated  with  fractures  of  the  lower  end  of  the 
radius.  It  was  formerly  believed  to  be  quite  rare,  but  careful 
examination  of  x-ray  plates  has  shown  that  it  is  relatively 
common.  Fracture  of  this  bone  is  infrequent  in  the  young. 
Between  the  ages  of  twenty  and  forty  it  is  generally  unassoci- 
ated  with  fracture  of  the  radius.  After  forty  it  is  seldom  simple, 
but  is  generally  associated  with  CoIIes's  fracture.  Fig.  92.  One 
of  the  fragments  may  or  msiy  not  be  displaced.  The  union  is 


88     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

generally  fibrous,  so  that  it  is  impossible  to  determine  by  the 
A-ray  whether  it  has  united  or  not,  as  no  callus  is  ever  thrown 
out.  W  hen  union  does  not  occur  the  fragments  may  remain  in 
apposition  for  years  and  then  some  slight  twist  of  the  wrist 
dislocates  one  of  the  fragments.  The  writers  have  seen  one 
case  where  the  fragment  was  dislocated  eight  years  after  the 
original  injury. 

Fracture   of  the  semilunar   is   next   in   frequency   but   is 
relatively  rare,  dislocation  being  more  common. 


Fig.  91.  Fig.  92. 

Fig.  91. — Fracture  of  the   scaphoid   of  the   wrist   without   displacement. 

Fig.  92. — CoIIes's  fracture  associated  with  fracture  of  the  scaphoid;  one, 

of  the  fragments  is  displaced. 

The  remainder  of  the  carpal  bones  are  but  infrequently 
fractured. 

Hand.  Fractures  of  the  metacarpal  bones  are  common 
accidents  but  not  so  frequent  in  the  young  unless  there  has 
been  a  crushing  injury.  Epiphyseal  separation  is  most  un- 
common. By  far  the  greater  majority  of  metacarpal  fractures 
occur  after  the  union  of  the  epiphysis,  and  they  are  much  more 
common  in  the  male  than  in  the  female.  The  second,  fourth 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


89 


and  fifth  metacarpals  are  more  frequently  broken.  The  third 
is  seldom  fractured.  The  fractures  are  of  two  varieties;  the 
most  common  is  just  below  the  head  of  the  bone  with  the 
head  displaced  toward  the  palmar  side  of  the  hand,  Fig.  93. 

The  oblique  fracture  (Fig.  94)  generally  invokes  the  shaft 
and  may  extend  almost  the  entire  length  of  the  bone; 
there  is  seldom  much,  if  any,  displacement. 

The  shaft  of  the  first  metacarpal  is  seldom  broken.  \\  hen 
a  fracture  occurs  in  this  bone  it  is  a  short  oblique  one  just 


Fig.  93.  FiG.  94.  Fig.  95. 

Fig.  93. — Fracture  of  the  distal  head  of  tlie  first  metacarpal  I)one,  with 

chsplacenicnt. 
Fig.  94. — Oblique  fracture  of  a  metacarpal  bone  without  disi^Iacemeiit. 
Fig.  95. — Fracture  of  the  base  of  tlie  first  metacarpal  with  anguhition. 

above  the  base,  starting  at  the  inner  side  and  extending 
downward  to  the  outer  side  of  the  bone.  Fig.  95.  This  tri- 
angular fragment  remains  in  situ,  but  the  shaft  is  displaced 
outward,  simulating  a  dislocation.  It  is  difficult  to  reduce. 
When  union  takes  place,  function  is  not  impaired,  but  there 
may  be  deformity. 


90     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS   , 

Fractures  of  the  phalanges  (Fig.  96)  are  generally  the  re- 
sult of  direct  violence  and  are  frequenth^  multiple;  some,  there- 
fore, maj'  be  unrecognized.  The  fragments  are  often  displaced. 
These  fractures  are  relatively  rare  in  the  young,  but  are  most 
common  in  men  between  the  ages  of  twenty  and  forty,  as 
that  period  may  be  termed  the  period  of  hazardous  employ- 
ment. These  fractures  alwaj^s  unite,  but,  since  they  are  due 
to  crushing  injuries,  they  are  either  compound  or  are  attended 


Fig.  96.  Fig.  g-^.  Fig.  98. 

Fig.  96. — Longitudinal   fracture  of  the  terminal   phalanx  of  the  thumb. 
Fig.  97. — Crushing  fracture  of  the  terminal  phalanx  with  osteomyehtis. 
Fig.  98. — A  small  fragment  of  bone  broken  off  from  the  articulating  surface 
of  the  terminal  phalanx,  producing  the  "base-ball  finger." 


with  lacerations,  so  that  osteomyelitis  is  a  common  sequela, 
with  the  joint  eventually  becoming  involved,  in  which  event 
an  ankylosis  (Fig.  97)  may  ensue.  The  first  and  second  pha- 
langes are  the  ones  most  commonly  broken. 

Besides  these  fractures  from  crushing  injuries  there  is 
also  the  "baseball  finger,"  Fig.  98.  When  such  a  finger  is 
examined  by  means  of  the  .v-ray  a  small  fragment  of  bone 
is  usually  found  broken  from  the  articulating  surface  of  one 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


91 


of  the  phalangeal  joints.  The  fragment  is  generalh'  pulled 
away  and  union  does  not  take  place.  It  frequently  acts  as  a 
foreign  body,  and  a  fibrous  ankylosis  of  the  joint  may  take 
place. 

Fractures  of  the  Trunk 

Ribs.     Fracture  of  the  ribs  is  probably  the  most  frequent 
of  all  injuries.   It  may  occur  at  any  age,  but  is  most  common 


Fig.  99. — Fracture  ol  sc\"cral  ribs  witli  slight  displacement. 

in  the  second  and  third  age  periods.  Such  fractures  are  gener- 
ally the  result  of  falls,  and  while  any  rib  may  be  involved  it 
is  very  unusual  to  see  the  hrst  rib  broken.  From  the  third 
to  the  ninth  rib  is  the  seat  of  the  usual  fracture;  above  and 
below  that  area  fractures  are  less  frequent.  They  generally 


Q2     INJURIES  AND  DISEASES  OE  BONES  AND  JOINTS 


EiG.  990. — Fracture   of  the   sternum   showing   lateral   displacement 


FRACTURES  OF  THE  UPPER  EXTREMITIES 


93 


Fig.   100. — Fracture  ol  the  upper  third  of  the  fenuir,  ihuin,  ischium  and 
pubis,  ckie  to  tlie  passage  of  a  heavy  wagon  wheel  over  the  peKis. 


occur  on  the  anterior  and  axillary  side  of  the  chest,  though 
occasionally  the  fracture  may  be  posterior,  close  to  the  spinal 
articulation.  They  are  generally  subperiosteal  in  character 
when  one  rib  is  broken,  Fig.  99.  If  several  ribs  are  broken 
they  may  be  displaced  and  one  of  the  fragments  may  even 
tear  or  puncture  the  pleura.  In  one  case  under  the  writers' 
observation  resulting  from  a  fall  from  a  horse,  the  third, 
fourth  and  fifth  ribs  were  broken  at  about  one  and  one-half 
inches  from  the  spinal  articulation.  The  short  fragments 
pierced  the  muscles  and  could  be  felt  lying  under  the  skin. 
Fractures  of  the  costal  cartilage  are  quite  common,  but 
unless  ossification  has  taken  place  this  condition   cannot  be 


94     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

demonstrated  by  means  of  the  .v-ray.  Fracture  of  the  ribs 
may  occur  and  the  position  be  such  that  it  cannot  be  demon- 
strated by  the  .v-ray.  \\  hen  no  fracture  can  be  demonstrated 
it  is  not  wise  to  make  a  positive  diagnosis  that  a  fracture  is 
not  present.  In  such  cases  it  has  always  been  the  writers'  habit 


Fig.   ioi. — ^Fracture  of  ischium   and  pubis,   ^^'ith  this  type  of  fracture 
there  is  seldom  displacement. 


to  return  a  diagnosis  of  "no  fracture  can  be  demonstrated." 
Sternum.  Fractures  of  the  sternum  are  relatively  rare 
and  very  difficult  to  demonstrate,  as  it  is  hard  to  get  a  clear 
view  of  the  sternum.  The  manubrium  is  most  common^ 
broken  and  the  fracture  is  of  the  depressed  variety.  Lateral 
displacement  rarely  if  ever  occurs,  Fig.  99a. 

Pelvis.  In  the  first  age  period  fractures  of  the  pelvis 
from  simple  injuries  are  most  uncommon.  In  severe  trauma, 
such  as  crushing  injuries  or  passage  of  heavy  vehicles  over 


FRACTURES  OF  THE  UPPER  EXTREMITIES        95 

the  body,  while  almost  any  type  of  fracture  may  occur, 
separation  along  the  epiphyseal  lines  is  most  frequent,  Fig.  100. 
It  is  in  the  second  age  period  that  we  find  the  greatest 
percentage  of  fractures.  Fracture  of  the  pubis  is  probably 
the  most  common  and  generally  takes  place  in  its  mid  portion 


Fig.   102. — Fracture  of  the  iiium  by  a  crushing  injury, 


with  but  fittle  displacement.  The  fracture  of  the  ischium  is 
next  in  frequency.  The  fracture  is  generally  near  the  pubis 
and  may  he  accompanied  b}^  displacement.  Fig.  loi.  Fractures 
of  the  iliac  bone  are  next  in  frequency,  occurring  usually 
along  the  long  axis  of  the  bone.  Fig.  102.  In  severe  crushing  acci- 
dents the  line  of  fracture  is  through  the  acetabulum  and  the 
lower  half  of  the  acetabulum  is  displaced.  In  one  instance  in  a 


96     INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

fall  from  a  height  where  the  patient  landed  on  his  feet,  the 
head  of  the  femur  was  driven  completely  through  the  ace- 
tabulum, Fig.  103. 

In  the  third  age  period  fractures  of  the  pelvis  are  not  so 
common  and  when  they  do  occur  the  pubis  and  ischium  are 
most  frequently  involved.  Since  most  of  these  fractures  occur 


Fig.   103. — Fracture  of  the  acetabulum  where  the  head  of  the  temur  has 
been  driven  through  and  is  resting  in  the  pelvic  canal. 

in  the  hazardous  occupations  it  follows  of  necessity  that  the 
vast  majority  of  such  injuries  are  sustained  by  males.  There 
is  one  type  of  injury,  however,  that  is  quite  common  in  the 
female,  especially  in  the  second  age  period  and  that  is  separa- 
tion of  the  symphysis  due  to  child  birth.  These  separations 
may  vary  from  one  quarter  of  an  inch  up  to  one  inch. 


CHAPTER  V 
FRACTURES  OF  THE  LOWER  EXTREMITIES 


CHAPTER  V 
Fractures  of  the  Lower  Extremities 

FEMUR.  Upper  End.  In  dealing  with  injuries  of  this 
portion  of  the  femur,  the  age  is  such  an  important  factor 
that  attention  is  again  called  to  the  three  age  periods: 

1.  Up  to  the  union  of  the  epiphyses. 

2.  From  union  of  the  epiphyses  up  to  fortj"  years  of  age. 

3.  Beyond  the  age  of  forty. 

In  considering  injuries  of  the  first  age  period,  as  has  been  so 
frequently  pointed  out,  we  have  the  ununited  epiphysis,  and 
this  epiphyseal  line  constitutes  the  weakest  portion  of  the 
bone  at  that  point.  It  is  a  well-known  dictum  that  a  chain 
is  only  as  strong  as  its  weakest  link,  and  the  weak  hnk  in  the 
neck  of  the  femur  is  its  epiphyseal  line.  Consequently,  when  an 
injury  occurs  in  this  region,  an  epiphyseal  separation  is  ex- 
pected and  not  a  fracture  of  the  neck,  and  in  the  experience 
of  the  writers  this  is  what  happens.  The  epiphyseal  head  is 
torn  off  and  remains  in  the  acetabuhim.  Fig.  104.  It  has 
rotated  shghtly  and  the  shaft  has  ridden  up.  The  separation 
is  seldom  complete,  so  that  if  untreated  union  will  always  take 
place;  but  on  account  of  the  rotation  of  the  head  and  the  riding 
up  of  the  shaft  there  will  be  a  shortened  leg  and  limitation  of 
abduction.  The  capsule  and  neck  are  much  stronger  than  the 
epiphyseal  line,  so  that  dislocation  or  fracture  of  the  neck  is 
extremely  rare. 

While  various  authorities  state  that  the  neck  of  the  femur 
in  the  young  is  fractured  more  frequently  than  is  commonly 
supposed,  yet  in  the  writers'  experience  it  is  most  uncommon. 
Only  one  such  case  has  come  under  our  observation.  We  are 
excluding  crushing  injuries,  such  as  those  caused  by  the  weight 
a  heavy  vehicle  or  by  falls  from  heights. 

In  the  second  age  period  fracture  of  the  neck  is  also  uncom- 

99 


100  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   104. — The  epiphyseal  separation  of  the  head  of  the  femur. 


FRACTURES  OF  THE  LOWER  EXTREMITIES       loi 


M. 


Fig.   105. — Fracture  of  the  neck  of  the  femur  just  behind  the  head. 


mon,  though  fracture  of  the  head  has  been  observed.  The 
capsule  in  this  period  seems  to  be  the  weakest  link  and  dis- 
location is  seen  oftener  than  fracture. 

It  is  in  the  last  age  period  that  most  of  the  fractures  of  the 
neck  occur,  and  they  are  more  common  in  the  female  than  in 
the  male.  In  one  winter  month  the  writers  saw  fifteen  such 
fractures,  of  which  thirteen  were  in  the  female.  This  percentage 
is  abnormally  high,  but  indicates  the  larger  proportion  in  the 
female.  The  neck  may  be  fractured  where  it  joins  the  head 
(Fig.  105),  in  its  mid  portion  (Fig.  106),  or  at  its  base,  Fig. 
107.  The  fragments  may  be  impacted  or  lying  free;  when  free 
the  x-ray  will  show  the  riding  up  of  the  shaft  and  the  trochanter 


102  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   io6. — Old  fracture  of  the  mid  portion  of  the  neck  of  the  femur  with 

absorption. 


rotated  posteriorly  indicating  the  outward  rotation  of  the  leg. 
Non-union  is  a  frequent  occurrence,  and  the  frequency  of 
non-union  increases  as  the  location  of  the  fracture  nears  the 
head.  When  the  fracture  remains  ununited  there  is  a  fairfy 
rapid  absorption  of  the  neck.  At  the  end  of  six  months  such 
fractures  have  been  observed  where  the  neck  has  been  com- 
pletely absorbed,  Fig.  io8.  When  the  fracture  is  just  behind  the 
head  or  in  the  middle  of  the  neck,  impaction  is  relatively  rare. 
Fracture  at  the  base  is  generally  impacted,  and  there  may  be 
more  or  less  coxa  vara.  Impacted  fractures  without  coxa  vara 
-are  sometimes  extremely  difficult  to  recognize.  If  a  second  x-ray 


FRACTURES  OF  THE  LOWER  EXTREMITIES       103 


"^r 


FiG.    107. — Fracture  through  the  trochanter,   involving    also   the  lesser 
trochanter  (intertrochanteric  fracture). 


104  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   io8. — Old,  ununited  fracture  of  the  neck  of  the  femur  with  complete 

absorption  of  the  neck. 


FRACTURES  OF  THE  LOWER  EXTREMITIES       105 


Fig.   109. — Healed  fracture  of  the  neck  of  the  femur.  No  cahus  could  be 

demonstrated. 


io6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

examination  is  made  at  the  end  of  two  weeks,  the  absorption  at 
the  ends  of  the  fragments  appears,  and  then  the  condition  is 
easil}"  recognized. 

Another   difficult   problem  for  the  roentgenologist  to  de- 


s 


Fig.   1 10. — Intertrochanteric  fracture  with  coxa  vara. 

termine  is  whether  union  has  taken  place  and  whether  it  is  safe 
to  place  weight  upon  the  leg.  As  the  union  in  these  fractures 
is  sometimes  fibrous  it  is  impossible  to  determine  that  point  in 
such  cases.  Even  when  bony  union  takes  place  there  may  be  no 


FRACTURES  OF  THE  LOWER  EXTREMITIES       107 

visible  callus  thrown  down,  and  again  the  roentgenologist  is 
placed  in  a  quandary,  Fig.  109.  It  has  been  the  writers'  practice 
never  to  return  an  aOirmative  opinion  unless  bonj'  callus  can 
be  demonstrated. 


Fig.  III. — Characteristic  position  ot"  a  fracture  of  the  upper  third  of  the 
femur.  Tliis  was  a  compound  fracture  into  which  Dakm  tubes  had 
been  introduced. 

In  considering  these  fractures  of  the  neck  of  the  femur 
according  to  the  age  periods  the  following  approximate  'Taw 
of  probabilities"  can  be  deduced.  In  the  first  age  period,  trauma 
generally  produces  an  epiphyseal  separation  and  rarely  a 
fracture  of  the  neck  or  a  dislocation.  In  the  second  age  period 
dislocation  is  themostcommoninjuryand  fracture  is  uncommon. 
In  the  third  age  period  fracture  is  very  common  and  disloca- 
tion is  uncommon. 

Fractures  iiuoKIno-  the  trochanters  are  frencralK    seen   in 


io8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  third  age  period.  The  fracture  is  generally  oblique,  starting 
through  the  greater  trochanter  or  at  its  junction  with  the  neck 
and  extending  downward  and  inward  to  a  point  just  below  the 
lesser  trochanter,  the  lesser  trochanter  frecjuently  forming  a 
fragment  by  itself,  Fig.  i  lo.  There  is  generally  no  displacement, 
but  a  riding  up  of  the  shaft  and  a  resulting  coxa  vara.  Union 


Fig.    112.  Fig.    113. 

Fig.    112. — Green-stick  fracture  of  the  femur  which   in   reduction   was 

made  complete.  Note  the  callus  formation. 
Fig.    113. — Transverse    fracture   of  the   femur    with    characteristic    dis- 
placement. 

always  takes  place  and  is  bon}"  in  character.  Fracture  ot  the 
trochanters  alone  is  unusual. 

Shaft.  Fracture  of  the  upper  third  of  the  femur  is  quite 
common  (Fig.  in),  and  the  fragments  assume  a  character- 
istic appearance,  that  is,  the  upper  fragment  is  displaced 
anteriorly  and  outward  while  the  lower  fragment  is  posterior 
and  inward.  The  separation  and  angukition  may  be  so  marked 


FRACTURES  OF  THE  LOWER  EXTREMITIES       109 

that  untreated  fractures  may  result  in  non-union.  The  fractures 
in  this  region  are  generally  oblique  and  may  occur  in  any  of 
the  age  periods.  The  only  difference  observed  is  that  transverse 
fractures  occur  more  frequently  in  the  first  age  period. 

Fractures  of  the  middle  third  of  the  shaft  are  common  in  all 
age  periods.  They  are  generally  oblique  or  green-stick  (Fig.  1 12) 
in  the  first  age  period.  In  the  second  and  third  age  periods  the 
fracture  is  frequently  transverse  and  there  is  generally  more  or 
less  displacement,  Fig.  113.  Non-union  is  frequently  due  to 
faulty  position  arising  from  muscle  and  periosteum  lying 
between  the  fragments. 

Lower  End.  In  the  first  age  period  the  lower  epiphysis 
is  sometimes  displaced.  When  this  happens  the  epiphysis 
is  generally  displaced  anteriorly  (Fig.  114),  occasionally 
posteriorly  and  the  periosteum  is  frequently  torn  away  from 
the  shaft  for  a  distance  of  several  inches,  Fig.  115.  The 
shaft  is  displaced  posteriorly  due  to  the  pull  of  the  gastroc- 
nemius. This  epiphyseal  separation  is  uncommon  and  seems  to 
be  associated  with  great  violence.  It  is  interesting  to  note  that 
in  the  writers'  series  of  cases  three  resulted  from  the  leg  being 
engaged  between  the  spokes  of  a  revoking  wagon  wheel. 

Oblique  fractures  are  occasionally  seen  occurring  just 
behind  the  condyles,  the  fracture  extending  from  the  front 
backwards. 

In  the  second  and  third  age  periods  as  in  the  first  age 
period  oblique  fracture  occurs  just  behind  the  condyles.  If  the 
fracture  is  above  the  attachment  of  the  gastrocnemius  the 
lower  fragment  will  be  posterior.  Occasionally  this  fracture  is 
associated  with  a  fracture  through  the  condyles  into  the  joints, 
Figs.  116  and  117.  The  condyles  may  be  separated  with  the 
shaft  lying  between.  Occasionally  there  may  be  a  fracture  of 
one  condyle  alone. 

In  severe  sprains,  occasionally  the  ligamentous  attachment 
will  be  pulled  off,  carrying  with  it  a  smafi  fragment  of  bone. 

Patella.  Fractures  of  the  patella  are  rarely  seen  in  the 
first  age  period,  and  while  occurring  in  the  second  age  period 


no  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   1 14. — Epiphyseal  separation  of  the  lower  end  of  the  femur  with  the 
epiphysis  displaced  anteriorly. 


FRACTURES  OF  THE  LOWER  EXTREMITIES       in 


Fig.  115. — Old  epiphyseal  separation  of  tiic  lower  end  of  tlic  femur  with 
the  epiphysis  displaced  posteriorly.  Note  stripping  up  of  the  periosteum 
with  new  bone  formation. 


112  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

are  most  common  after  forty.  They  are  much  more  frequent 
in  the  male  than  in  the  female.  They  generally  result  from 
a  fall  upon  the  knee;  but  the  writers  have  seen  such  fractures 
resulting  from  violent  contractions  of  the  quadriceps. 


Fig.  1 1 6. — Oblique  fracture  of  the  lower  end  of  the  femur  associated  with 
a  fracture  through  the  condyles  and  into  the  joint. 

In  those  resulting  from  falls  the  fracture  may  be  simple 
or  comminuted,  depending  upon  the  severity  of  the  injury. 
The  fractures  are  generally  anteroposterior,  and  the  anterior 
third  is  the  most  frequently  fractured. 

If  the  quadriceps  fascia  over  the  patella  is  intact  there 


FRACTURES  OF  THE  LOWER  EXTREMITIES 


1 1 


is  seldom  displacement,  Fig.  ii8.  When  it  is  torn  the  frag- 
ments may  be  widely  separated  (Fig.  119),  the  lower  frag- 
ment sometimes  resting  over  the  articulating  surface  of  the 
tibia  and  rotated.  When  the  fragments  are  approximated  the 


Fig.   1 17. — Lateral  view  of  Fig.  1 16  showing  the  hne  of  fracture. 


union  is  generally  fibrous  and  less  frequently  bon\'.  There 
again  it  is  difficult  for  the  roentgenologist  to  determine  whether 
proper  union  has  taken  place. 

Tibia  and  Fibula.  Upper  End.  In  the  first  age  period, 
although  the  epiphyses  are  present,  dislocation  of  them  is 
most  unusual.  The  writers  have  never  had  such  a  case  under 

8 


114  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

observation.    The   tibial    tubercle,    however,    has    a   separate 
center  of  ossification,  and  this  may  be  pulled  loose  by  muscular 


Fig.   ii8.  Fig.   119. 

Fig.    118. — Fracture  of  the  patella  without  displacement  as  the  fibrous 

sheath  of  the  patella  is  intact. 
Fig.   119. — Fracture  of  the  patella  with  wide  separation  of  the  fragments 

due  to  a  torn  sheath. 


Fig.   120. — Fracture  of  the  tibial  tubercle. 

violence  or  broken  by  direct  violence.  The  writers  have  seen 
several  instances  where  the  tubercle  was  broken  by  falling 
on  a  sharp  edge,  as  the  edge  of  a  curb  stone.  Fig.   120. 


FRACTURES  OF  THE  LOWER  EXTREMITIES       115 

Fractures  through  the  heads  of  the  tibia  and  fibula  are 
unusual  in  this  age  period.  In  the  second  and  third  age  periods 
fracture  of  the  heads  of  these  bones  is  quite  common,  and 
with  the  tibia  there  is  generally  a  fracture  of  one  of  the  tuber- 
osities, Fig.  121.  The  tuberosity  is,  as  a  rule,  forced  outwards 
and  frequently  is  displaced  slightly  posteriorly.  Sometimes  we 
have  the  tuberosity  broken  off  without  a  transverse  fracture 


Fig.   121. — Fracture  of  the  tuberosity  of  tibia. 

of  the  tibia.  Fractures  of  the  head  of  the  fibula  may  occur 
without  a  fracture  of  the  tibia,  but  they  are  more  frequently 
associated  with  fracture  of  the  middle  third  of  the  shaft  of 
the  tibia,  Fig.  122, 

In  injuries  around  the  knee  joint  the  tibial  spines  should 
always  be  carefully  inspected,  as  one  or  both  may  be  broken. 
This  injury  is  much  more  frequent  than  has  been  suspected 
(Fig.    123),   and   a  routine  .v-ray  examination  should  always 


ii6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

be  made  in  slight  injuries  or  sprains  of  the  knee.  This  fracture 
is  frequently  associated  with  dislocations  of  the  semilunar 
cartilages. 

Shaft.  Fractures  of  the  shaft  are  common  in  both  bones, 
and  are  generally  associated.  Fracture  of  the  tibia  alone  is 
quite  common,  while  fracture  of  the  shaft  of  the  fibula  alone 


Fig.  122. — Fracture  of  the  upper  end  of  the  tibula  associated  with  frac- 
ture of  the  middle  third  of  the  tibia.  (Mottled  effect  due  to  an  unusu- 
ally dense  plaster  cast.) 

is  rare.  When  the  libula  is  fractured  alone  the  injury  is  either 
at  the  upper  or  lower  end.  There  is  no  one  definite  fracture 
of  the  shaft  of  the  tibia.  It  assumes  a  variety  of  forms.  In  the 
first  age  period  it  ma}'  be  of  the  green-stick  variety  or  oblique, 
Fig.  124.  At  the  end  of  the  first  age  period  and  the  beginning 
of  the  second  age  period  the  fractures  are  oblique  (Fig.  125) 
or  spiral   (Fig.    126)   and  occasionally  transverse   (Fig.    127), 


FRACTURES  OF  THE  LOWER  EXTREMITIES       ii" 

while  in  the  third  age  period  they  are  generally  transverse 
and  frequently  comminuted.  In  the  first  two  age  periods 
non-union  is  uncommon,  while  in  the  third  age  period  non- 
union occurs  quite  frequently. 

Lower     End.      In     the     hrst     age     period    separation    of 
the    epiphyses   of  the  tibia  with  or  without   displacement   is 


Fig.    123.- — Fracture  of  the  external  tibial  spine,  frequently  mistaken  for 

a  simple  sprain. 

quite  common,  Fig.  128.  Separation  of  the  epiphj^ses  of 
the  fibula  is  quite  uncommon.  When  the  epiphyses  of  the 
tibia  is  dislocated  it  is  generally  associated  with  a  fracture 
of  the  lower  end  of  the  fibula.  In  this  period  linear  fractures 
of  the  tibia  are  also  seen  extending  from  the  joint  upwards 
into  the  shaft,  but  with  no  displacement.  In  the  second 
and  third  age  periods  fractures  around  the  ankle  joint 
are  extremely  common.  The  lower  three  inches  of  the  fibula 
(Fig.  I2q)  is  the  site  of  more  fractures  than  an\'  other  portion 
of  the  bones  of  the  leg.  The  fracture  is  generally  oblique,  and 
may  or  may  not  be  displaced.  When  displaced  the  lower  frag- 
ment is  usually  posterior. 


ii8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   124.  Fig.   125. 

Fig.   124. — Green-stick  fracture  of  the  tibia  in  the  first  age  period. 

Fig.    125. — Obhque  fracture  of  the  tibia  in  the  first  age  period. 


Fig.    126.  Fig.    127. 

Fig.   126. — Spiral  fracture  of  the  tibia  in  the  first  age  period. 

Fig.    1 2-. — Comminuted  fracture  of  tibia  and  fibula  in  the  third  age  period. 


FRACTURES  OF  THE  LOWER  EXTREMITIES       119 

When  both  bones  are  broken  Pott's  fraeture  is  the  most 
common,  Fig.  130.  This  is  a  fracture  of  one  or  both  malleoli 
of  the  tibia  and  of  the  lower  end  of  the  fibula.  With  this  fracture 
there  is  extensive  tearing  of  the  ligaments  and  there  will  often 


Fig.   128.  Fig.   129. 

Fig.   128. — Slight  epiphyseal  separation  of  the  lower  end  of  the  tibia  with  a 

fragment  of  bone  torn  from  the  tibia. 

Fig.   129. — Fracture  of  the  lower  end  of  the  tibia. 

be  a  dislocation  of  the  foot,  Fig.  131.  These  fractures  are  gener- 
ally associated  w  ith  more  or  less  deformity. 

In  examinations  of  the  ankle  joint  special  attention  should 
be  given  to  the  shadows  of  the  soft  tissues  in  the  lateral  view, 
as  they  will  frequently  aid  in  determining  the  presence  or 
absence  of  injury  or  disease.  In  the  lateral  view  a  black  triangle 


120  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

(Fig.  132)  is  formed  by  the  os  calcis,  the  tendo  Achillis  and  the 
posterior  tibial  muscles.  The  os  calcis  forms  the  base  of  the 
triangle,  and  the  apex  is  about  three  inches  above  where  the 
belly  of  the  muscle  begins.  This  triangle  is  normally  filled  with 
fat,  and  ofl'ers  very  little  resistance  to  the  x-ray,  so  that  it 
appears   black   upon   the   plate.   Any   injury   or   disease   will 


Fig.   130.  Fig.    131. 

Fig.   130. — Typical  Pott's  fracture,  anteroposterior  view. 
Fig.   131. — Lateral  view  of  a  Pott's  fracture  associated  with  a  posterior 

dislocation  of  the  foot. 

cause  it  to  become  filled  with  blood  or  inflammatory  tissue, 
and  the  triangle  becomes  obliterated.  Fig.  133.  When  the 
triangle  is  absent  the  plates  should  be  carefully  examined,  as 
this  is  an  indication  of  injury  or  disease. 

Bones  of  the  Foot — Astragalus.  Fracture  of  the  astrag- 
alus is  generally  the  result  of  a  fall  from  a  height,  followed  by 
a  landing  on  the  feet,  Fig.  134.  The  fracture  is  generally 
transverse,  and  displacement  depends  upon  the  degree  of 
violence.  It  occurs  usually  in  the  second  and  third  age  periods. 


122  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

Following  injuries  of  the  ankle  joint  one  frequently  sees  a 
small  fragment  of  bone  lying  close  to  the  posterior  border  of  the 


Fig.   134. — Fracture  of  the  astragalus  with  separation  of  the    fragments 


Fig.    135. — Fracture    of   the    end    of   the    astragahis    simulating    an   os 

trigonum. 

astragalus.  Many  writers  claim  this  fragment  to  be  a  small 
independent  bone,  namely  the  os  trigonum.  In  a  number  of 
cases  in  our  series  the  writers  were  fortunate  enough  to  have  by 
chance  plates  of  the  ankle  before  injury  showing  no  os  trigonum, 


FRACTURES  OF  THE  LOWER  EXTREMITIES       123 

and  a  later  plate  following  an  injury  showing  this  fragment, 
indicating  that  this  was  the  result  of  the  injury,    Fig.    135. 


Fig.   136.  Fig.    137. 

Fig.   136. — Fracture  of  the  os  calcis  due  to  a  crushing  injury. 

Fig.   137. — Fracture  of  the  tip  of  the  scaphoid.  .Most  frequently  seen  in  toe 

dancers. 


Os  Calcis.  Like  the  astragalus  this  bone  is  broken  in  falls 
from  heights,  Fig.  136.  In  the  writers'  series  of  cases  ft  was 
found  that  the  niajorit}-  of  such  fractures  were  sustained  by 
carpenters,  bricklayers,  riveters,  etc.,  whose  occupations 
necessitating  work  upon  scaffolds.  This  also  indicates  that 
these  fractures  occur  in  the  second  and  third  age  periods.  These 
fractures  may  be  simple  or  comminuted  according  to  the 
severity  of  the  trauma.  In  several  instances  violent  muscular 
tension  has  caused  the  tendo  Achillis  to  pull  off  a  fragment  of 
bone  at  the  attachment. 

Scaphoid.  Fracture  of  the  scaphoid  is  seen  frequently 
in  crushing  injuries.  Two  cases  have  been  observed  where  the 
internal  portion  was  pulled  off  in  dancers  performing  the 
ballet.  Fig.  137. 

Cuboid  and  Cuneiforms.  The  only  fractures  observed  in 
these  bones  were  due  to  crushing  injuries,  caused  by  great 


124  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   138. — Old  fracture  of  the  cuboid,  with  some  callus  formation. 


A 


Fig.   139. — Fractures  of  all  the  metatarsals  and  some  of  the  phalanges 
due  to  a  crushing  injury. 


FRACTURES  OF  THE  LOW  ER  EXTREMITIES       125 

weights   falling  on   the  foot,  or  the  passage  of  a  hea\  y  wagon 
wheel,  Fig.  138. 

Phalanges.  These  fractures  are  due  to  direct  violence 
and  like  those  in  the  hand  may  be  compound  and  associated 
with  infection,  Fig.  139. 

Metatarsal  Bones.     The  metatarsal  bones  are  frequent 
fractured  as  the  result  of  falls  and  crushing  injuries,  Fig.  139. 
The  base  of  the  fifth  metatarsal  is  so  often  fractured  as  to 
warrant  especial   mention.    It   is   generally   due   to   muscular 
violence.  Fig.  140. 


Fig.   140. — Fracture  of  the  base  of  the  lifth  metatarsal. 

Sesamoids.  Fractures  of  one  of  the  sesamoids  is  a  rare 
injury.  The  other  foot  should  always  be  examined,  as  some- 
times three  sesamoids  are  present  and  one  of  these  might  be 
mistaken  for  a  fragment  in  the  injured  foot. 

NON-UNION 

In  the  beginning  of  the  previous  chapter  we  outlined  in  a 
general  way  the  conditions  that  lead  up  to  the  production  of 
fractures,  and  how  age,  sex  and  occupation  play  an  important 


126  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


role.  There  is  one  other  condition  to  which  attention  must  be 
called  and  that  is  non-union.  This  is  frequently  encountered, 

and  certain  bones  are  more  sub- 
ject to  it  than  others. 

How  can  an  old  ununited 
fracture  be  differentiated  from  a 
fresh  one  where  sufficient  time 
has  not  elapsed  for  callus  to 
form?  In  an  old  ununited  frac- 
ture extreme  atrophy  of  bone 
and  soft  tissues  are  found  and 
the  broken  ends  are  smooth, 
having  lost  the  irregular  serrated 
edge  of  the  fresh  fracture.  Fig. 
141.  In  a  recent  fracture  there  is 
but  little  atrophy  of  the  bone 
and  soft  tissues.  By  the  time 
atrophy  begins  in  a  fresh  frac- 
ture callus  should  be  visible,  and 
a  mistake  in  diagnosis  should 
not  be  made. 

Changes  are  seen  upon  a 
plate  that  will  aid  in  the  recogni- 
tion of  some  of  the  causes  of  non- 
union. The  most  obvious  one  is 
where  the  fragments  are  so 
widelj''  separated  that  union  can- 
not take  place.  In  other  frac- 
tures, there  will  be  actual  necro- 
sis of  the  ends  of  the  bone,  due 
to  the  rupture  of  a  blood  vessel, 
thus  bringing  about  non-union. 
In  certain  lesions,  such  as  sar- 
coma and  carcinoma,  the  destruction  of  the  bone  will  pro- 
duce a  fracture,  and  it  will  of  necessity  not  unite.  In  the 
virulent  stage  of  an  acute  osteomyelitis  a  fracture,  if  present, 


Fig.  141. — Old  fracture  of  tibia 
with  bone  graft  showing 
atrophy  and  smooth  edges 
in  an  ununited  fracture. 
Fragments  of  fibula  re- 
moved. (Taken  through  a 
heavy  plaster  cast.) 


FRACTURES  OF  THE  LOWER  EXTREMITIES       127 

will  not  unite  until  the  lesion  is  halted.  When  the  bones  are  in 
good  alignment  but  separated  by  a  space,  shown  upon  the 
plate,  that  generally  means  that  muscle  or  fascia  is  in  between 
the  fragments,  and  again  there  will  be  no  union.  There  are, 
however,  a  certain  percentage  of  cases  where  none  of  the  above 
causes  exist,  but  in  which  union  will  not  take  place.  We  do  not 
know  the  cause,  but  it  must  be  due  to  some  alteration  in 
metabolism  probably  secondary  to  faulty  blood  supply. 
While  non-union  may  occur  at  any  age  if  the  fragments  are 
widely  separated,  it  is  in  the  second  and  third  age  periods 
that  it  is  most  frequently  met  with.  Probably  the  changes 
due  to  old  age  are  an  added  factor  to  other  unknown  causes. 

The  humerus  and  femur  are  the  two  bones  in  which  this 
condition  occurs  most  frequently,  and  the  ununited  fractures 
of  the  neck  of  the  femur  are  the  most  common.  Probably  one 
of  the  causes  in  fracture  of  the  neck  of  the  femur  is  the  non- 
approximation  of  the  fragments;  but  even  when  operated 
upon  and  the  fragments  pegged,  a  large  percentage  of  cases 
fail  to  unite.  The  blood  supply  in  this  area  is  not  particularly 
good,  and  this  may  be  one  of  the  factors. 

Bone  Splints.  Since  the  roentgenologist  has  to  deal 
with  non-union,  the  operative  procedures  to  relieve  this 
condition  must  of  necessity  be  examined  also,  so  he  must  be 
thoroughly  familiar  with  the  various  bone  splints.  Special 
attention  is  called  to  the  intermedullary  bone  graft.  This 
graft,  generally  taken  from  the  tibia,  is  introduced  into  the 
medullary  canal,  and  at  first  is  a  tight  fitting  bone  splint 
(Fig.  142) ;  but  as  time  goes  on  a  vacuolated  area  from  pressure 
atrophy  forms  around  the  splint,  especially  at  each  end. 
The  writers  have  seen  this  mistaken  for  an  osteomyelitis 
when  in  reality  it  is  merely  a  pressure  absorption,  Fig.   143. 

Do  not  look  for  union  of  the  intermedullary  graft  and 
bone,  as  this  does  not  take  place;  the  graft  only  acts  as  a 
mechanical  splint,  and  is  eventually  absorbed.  The  graft  at 
times  may  be  broken  while  in  situ  and  this  should  always  be 
looked  for  and  reported  if  present.  Fig.  144. 


128  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  142. 


-Bone  transplant  of  the  upper  end  of  the  humerus.  The  transplant 
employed  is  the  upper  end  of  the  fibula. 


Fig.   143. 


-Pressure  atrophy  around  the  ends  of  the  bone  graft.   (Taken 
through  a  heavy  plaster  cast.) 


FRACTURES  OF  THE  LOWER  EXTREMITIES       129 


Fig.    144.  Fig.    145. 

Fig.   144. — Old  fracture  of  the  humerus  with  bone  graft  \\hich  is  broken 

and  partially  absorbed. 
Fig.   145. — Metal  plate  which  has  worked  loose  and  is  now  acting  as  an 

irritant. 


Other  splints,  such  as  Lane  plates,  wires,  etc.,  should  be 
carefully  examined  to  see  whether  the  plate  is  firmly  attached. 
The  splint  may  work  loose  and  act  as  an  irritant,  Fig.   145. 

The  roentgenologist  should  also  be  familiar  with  the 
appearance  of  the  tibia  after  a  piece  of  bone  has  been  removed 
for  grafting  purposes,  Fig.  146.  The  area  from  which  the 
bone  has  been  removed  may  be  mistaken  for  some  pathological 
condition. 

Where  there  has  been  surgical  interference  in  a  fracture 
it  has  been  the  experience  of  the  writers  that  repair  takes 
place  more  slowly  and  consequently  caHus  does  not  appear 


130  INJURIES  AND  DISEASES  OE  BONES  AND  JOINTS 

as  early  as  one  would  expect.  In  cases  of  non-union  after 
surgical  interference,  if  union  takes  place  repair  is  a  very- 
slow  process.  The  writers  have  seen  a  year  elapse  before  any 


Fig.    146. — Tibia  after  a  bone  graft  has  been  removed. 


callus  could  be  demonstrated.  The  roentgenologist  should  be 
very  guarded  in  his  expression  as  to  whether  union  will  eventu- 
alh'  take  place  or  not. 


CHAPTER  VI 
CONGENITAL  DISLOCATIONS 


CHAPTER  VI 

Congenital  Dislocations 

WHILE  congenital  dislocations  have  been  noted  in 
many  of  the  joints,  yet  with  the  exception  of  the 
hip  they  are  uncommon.  The  etiological  factor  has 
not  been  dehnitely  estabhshed,  but  some  malposition  of  the 
parts  in  fetal  hfe  may  be  the  causal  factor.  In  the  newborn  the 
heads  of  the  bone  are  entirely  cartilaginous  and  cannot  be 
demonstrated  by  the  x-ray,  so  in  some  cases  injuries  at  birth 
may  deform  or  displace  the  head,  and  later  on  these  disloca- 
tions be  termed  congenital.  Congenital  dislocations  of  the  hip 
cannot,  however,  be  attributed  entirely  to  birth  injuries,  as 
under  such  conditions  the  percentage  of  cases  should  be  equally 
distributed  between  the  male  and  female,  whereas  the  lesion 
occurs  much  more  frequently  in  the  female. 

Congenital  Dislocation  of  the  Hip.  This  condition  is 
seldom  recognized  at  birth.  The  abnormal  condition  of  the  hip 
is  only  noted  some  time  after  the  child  has  started  to  walk. 
The  waddling  gait  at  first  is  thought  to  be  simply  awkward 
efforts  in  learning  to  walk.  When  this  does  not  clear  up  medical 
advice  is  sought.  The  fact  that  the  child  is  seen  after  it  has 
learned  to  walk  has  an  important  bearing  upon  the  .v-ray 
findings.  In  studying  the  plate  of  such  a  case,  there  are  several 
points  which  should  be  carefully  noted — the  shape  of  the 
pelvis,  the  position  and  shape  of  the  head  and  neck  of  the  fe- 
mur, and  the  size  of  the  atlected  bone  in  comparison  with  the 
normal  one. 

In  a  newly  born  child  and  until  walking  takes  place,  the 
pelvis,  roughly  speaking,  is  triangular  in  shape,  with  the  base 
above  and  the  apex  at  the  pubis.  The  two  sides  of  the  triangle 
are  approximately  straight  (Fig.  147);  but  when  the  child 
walks,  the  upward  thrust  of  the  femur  localized  at  the  ace- 

133 


134  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

tabulum,  which  is  the  point  of  articulation,  gradually  causes 
the  acetabulum  to  be  pushed  in  slightly,  and  at  this  age,  the 
bones  being  soft,  this  is  easily  accomplished.  At  the  same  time 
the  body  weight  exerting  a  downward  pressure  causes  the  ilia 
to  flare  out.  These  two  mechanical  factors  change  the  shape  of 
the  pelvis,  so  that  where  it  was  triangular  with  straight  sides 
before  walking,  it  has  now  become  a  triangle  with  the  base 
slightly  widened  and  the  sides  slightly  curved,  the  convexity  be- 
ing inward.  Fig.  148.  This  naturally  gives  a  stronger  joint  and  one 
in  which  dislocation  is  less  apt  to  occur.  When  one  hip  is   dis- 


FiG.   I4~. — Straight  ^icle-  of  a  pelvis  in  a  child  who  has  not  walked. 

located  that  side  of  the  triangle  will  be  found  straight  and 
the  other  slightly  bent  in.  The  acetabulum  will  also  be  shallow, 
as  there  will  have  been  no  pressure  from  the  femur  to  deepen  it, 
Fig.  149.  The  dislocation  is  generally  upward,  so  the  trochanter 
will  be  high.  The  neck  is  also  frequently  bent,  and  this  may 
throw  the  head  anteriorly  and,  from  its  appearance  upon  the 
plate,  suggest  that  it  may  have  been  destroyed  by  disease. 
Congenital  dislocations  are  found  at  the  age  when  acute 
epiphysitis,  tuberculous  and  non-tuberculous,  is  prevalent. 
In  these  two  conditions,  however,  not  only  will  the  head  be 
partially  or  wholly  destroyed,  but  the  acetabulum  will  also 


CONGENITAL  DISLOCATIONS 


135 


Fig.    148. — Beginning   concavity    of  the  sides  of  the  pelvis  ckie  to   the 
upward  thrust  of  the  femora  in  walking. 


Fig.  149. — Congenital  dislocation  of  the  hip.  The  acetabulum  is  shallow 
and  there  is  no  concavity  of  the  pelvis  on  the  aOected  side.  Note  the 
distance  of  the  dislocated  head  of  the  femur  from  the  acetabulum. 


136  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

be  more  or  less  involved,  Fig.  150.  In  congenital  dislocation  the 
acetabulum  will  be  shallow  and  the  outhnes  clean-cut,  but 
there  will  be  no  destruction.  If  the  disease  takes  place  after  the 
child  has  walked  there  will  also  be  the  bent  side  of  the  tri- 


FiG.  150. — Destruction  of  the  head  of  the  femur  with  pathological  disloca- 
tion. The  acetabulum  is  also  involved.  The  destruction  allows  the  neck 
and  shaft  to  lie  close  to  the  pelvic  wall  with  no  intervening  space. 
Compare  this  with  the  space  seen  in  congenital  dislocation,  Fig.  149. 

angle,  while  in  dislocation  it  will  be  straight.  Then,  too,  in  the 
non-tuberculous  epiphysitis  there  will  be  new  bone  formation 
in  the  late  stages  and  this  is  never  present  in  dislocation, 
Fig.  151.  Occasionally  one  will  find  a  new  small  acetabulum  on 


CONGENITAL  DISLOCATIONS 


137 


the  posterior  surface  of  the  ilium  in  dislocation.  In  diseased 
processes,  as  a  rule,  the  trochanter,  besides  being  high,  is 
closer  to  the  bone  on  account  of  destruction,  while  in  disloca- 
tion a  wide  space  generally  separates  the   femur   from   the 


Fig.   151. — Bony  ankylosis  seen  in  non-tuberculous  infections. 

pelvis.  In  congenital  dislocation  the  femur  on  the  aflected  side 
will  be  smaller  than  the  normal  one,  due  to  retarded  develop- 
ment probably  from  lack  of  bone  stimulation.  This,  however,  is 
also  seen  when  the  head  has  been  destroyed  by  disease,  Fig.  152. 
Congenital  dislocation  of  the  hip  is  much  more  common  in 
the  female,  being  in  the  proportion  of  six  or  seven  to  one  in  the 
male.  Either  hip  may  be  involved;  in  the  writers'  series  of 
cases  the  distribution  w^as  about  equal.  Dislocation  of  both  hips 


138  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fk;.    152. — The  small  undeveloped  femur  in  congenital  dislocation.  This 
is  not  "atrophy  of  quantity"  but  non-development. 


Fig.   153. — Congenital  dislocation  of  both  hips.  Note  the  shallow  acetabula 
and  straight  sides  of  the  pelvis. 


CONGENITAL  DISLOCATIONS 


139 


Fig.    154. — Injury   of  the  lower  epiphysis  with  consequent   retardation 
of  growth  causing  a  partial  subluxation  of  the  ankle  joint. 


Fig.   155. — Club  foot. 


Fig.   156. — Club  hands. 


140  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.    iy~. — Abnormal  position  of  femur  due  to  anterior  poliomyelitis.  Tiiis 
hip  could  be  dislocated  with  but  shght  manipulation. 


CONGENITAL  DISLOCATIONS  141 

occurred   in  about   30  per  cent  of  the  total  number  of  cases, 

Fig-  153- 

Dislocations  of  the  Shoulder  Joint.     In  dislocations 

of  other  joints  birth  injuries  play  a  most  important  part,  and 
this  is  particularly  true  of  the  shoulder  joint.  As  has  already 
been  stated,  injuries  to  the  humeral  head  may  occur  without 
being  recognized  and  only  be  discovered  later  in  life.  Obstet- 
rical paralysis  may  cause  subluxations  and  these  later  may  be 
called  congenital. 

Abnormalities  in  the  Development  of  Epiphyses. 
Any  abnormality  in  the  development  of  the  epiphysis,  cither 
over-development  or  retardation,  may  bring  about  mechanical 
dislocation.  The  writers  have  seen  several  cases  where  the 
epiphyseal  head  of  one  of  the  bones  of  the  leg  or  forearm 
failed  to  develop.  This,  of  course,  retarded  the  growth  of  the 
bone,  and  with  the  normal  increase  in  the  length  of  the  adjacent 
bone  mechanically  brought  about  a  dislocation,  Fig.  154.  In  club 
foot  (Fig.  155)  and  club  hand  (Fig.  156)  partial  or  complete 
dislocations  may  occur,  just  as  in  obstetrical  paralysis  we  may 
find  a  dislocation  of  the  hip  due  to  anterior  poliomyelitis, 
Fig.  157. 


CHAPTER  VII 
ACQUIRED  DISLOCATIONS 


CHAPTER  VII 

Acquired  Dislocations 

DISLOCATIONS  arc  not  often  seen  by  the  roentgen- 
ologist before  being  reduced.  The  majority  are  re- 
duced and  then  sent  for  .v-ray  examination  to  see  if 
the  reduction  is  proper  or  to  rule  out  a  possible  fracture.  In 
the  writers'  series  of  cases  the  percentage  of  shoulder  disloca- 
tions is  very  small,  due  to  the  above  fact.  In  hospital  and 
out-patient  departments,  practically  every  fracture  is  seen 
before  and  after  reduction,  while  dislocations  are  generally 
seen  only  after  reduction. 

Shoulder.  In  the  first  age  period  dislocations  of  the 
shoulder  are  rare,  though  occasionally  one  ma}'  result  from 
instrumental  delivery.  The  second  age  period  shows  the  great- 
est number  of  dislocations,  and  they  are  largely  confined 
to  the  male.  This  period  covers  the  age  of  hazardous  occupa- 
tions, and  since  the  female  does  not  engage  in  such  pursuits 
dislocations  are  relatively  rare.  The  various  text  books  of 
surgery  give  percentages  covering  the  different  types  of  dis- 
locations. From  personal  observation  the  subcoracoid  (Fig. 
158)  has  been  found  to  be  by  far  the  most  common,  and  the 
variations  of  the  subglenoid  type  (Figs.  159  and  160)  are  pro- 
bably next  in  frequenc}'. 

Dislocations  in  the  third  age  period  are  generally  the  result  of 
falls  and  occur  with  the  same  relative  frequency  in  both  sexes.  In 
this  age  period,  however,  we  find  that  these  dislocations  are 
often  associated  with  fractures  of  the  greater  tuberosity  or  of 
the  surgical  neck.  It  is  common  to  see  a  fracture  of  the  surgical 
neck  with  the  end  of  the  shaft  in  the  glenoid  fossa  and  the 
head  dislocated  outward,  Fig.  161.  In  these  cases  one  wonders 
whether  the  dislocation  is  the  result  of  the  fracture  or  vice 
versa.  Occasionally  one  will  see  the  head  split  longitudinally 
with  a  portion  of  it  in  the  axilla. 
10  145 


146  INJURIES  AND  DISEASES  OF  BOXES  AND  JOINTS 

Elbow.  Dislocations  of  this  joint  appear  \\  ith  the  same 
relative  frequency  as  to  age  and  sex  as  those  of  the  shoulder. 
They  are  much  more  common  in  the  male,  and  occur  most 
often  between  the  ages  of  twenty  and  forty. 

In  the  first  age  period  dislocations  of  the  elbow  are  relatively 
rare.  In  some  of  the  older  works  it  is  stated  that  the  great 
majority  of  the  dislocations  of  the  elbow  occur  under  twenty  and 
that  half  of  them  occur  under  the  age  of  ten.  The  writers  have 


Fig.   158. — Subcoracoid  dislocation  ut  the  humerus. 

seen  many  cases  in  young  children  diagnosed  as  dislocations, 
in  which  the  .v-ray  examination  has  shown  that  the  condition 
was  one  of  epiphyseal  separation  or  a  supracondyloid  fracture. 
It  is  reasonable  to  suppose  that  the  epiphyseal  line  is  weaker 
than  the  capsule,  and  consequently  we  have  separation  instead 
of  dislocation.  Most  of  these  dislocations  are  encountered 
in  the  latter  portion  of  the  first  age  period  and  the  first  half  of 
the  second  age  period.  Dislocation  of  both  bones  backward  is 
b}'  far  the  most  common,  with  its  \'ariations  of  outward  and 


ACQUIRED  DISLOCATIONS 


147 


Fig.   159. — Subglenoid  dislocation  with  unusual  position  of  the  humerus. 
(Courtesy  oj  Dr.  Henry  J.   Walton.) 


Fig.   160. — Subglenoid  dislocation.  The  usual   po^iiujn    of  the  humerus. 
(Courtesy  of  Dr.  Henry  J.  Walton.) 


148  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

inward,  Fig.  162  and  163.  Dislocation  forward  is  apparently  a 
very  rare  condition.  These  dislocations  are  frequently  associ- 
ated with  fractures  of  the  coronoid,  olecranon  and  head  of  the 
radius. 

Ulna  and  Radius.  The  ulna  is  sometimes  dislocated 
backwards  v>ith  an  accompanying  fracture  of  the  radius. 
The  radius   may  be  dislocated   forward    (Fig.    164   and    165) 


Fig.   161. — -Subglenoid  dislocation  of  the  humerus  associated  with  fracture, 
the  shaft  resting  in  the  glenoid  fossa.  (Courtesy  oj  Dr.  John  Evans.) 

without  fracture,  but  when  dislocated  forward  and  upward  it 
is  invariably  associated  with  a  fracture  of  the  upper  third  of 
the  ulna. 

In  the  extensive  tearing  of  the  ligamentous  attachments 
in  dislocations  there  sometimes  follows  a  partial  or  complete 
ossification  of  the  capsule  with  a  resulting  stiff  joint.  Fig.  166. 

In  the  third  age  period  dislocations  are  uncommon.  Injuries 


ACQUIRED  DISLOCATIONS 


149 


Fig.   162.  Fig.   163. 

Fig.  162. — Dislocation  of  both  bones  of  the  forearm  backward,  associated 

with  fracture.  {Courtesy  of  Dr.  Henry  J.  \Valto7i.) 

Fig.   163. — Another  view  of  the  condition  indicated  in  Fig.  162,  showing  the 

lateral  clisi)lacfnient.  (Courtesy  of  Dr.  Henry  J.  Walton.) 


Fig.   164.  Fig.   165. 

Fig.   164. — Dislocation  of  the  elbow  associated  with  fracture  of  tlie  neck 

of  the  radius.  (Courtesy  oj  Dr.  Henry  J.  Walton.) 
Fig.    165. — Same  as   Fig.    164,   showing  lateral   view.    (Courtesy   oj  Dr. 

Henry  J.  Walton.) 


150  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.    1 66. — Dislocation  of  the  elbow  reduced,  followed  by  deposition  of 
bone  in  the  torn  hgaments  producing  ankylosis. 


Fig.   167.  Fig.   168, 

Fig.   167. — Dislocation  of  the  wrist  joint. 
Fig.   168. — Anterior  dislocation  with  rotation  of  the  scmihinar. 


ACQUIRED  DISLOCATIONS 


ItI 


producing    dislocations    in    the    second    age    period    produce 
fractures  in  the  third  age  period. 

Wrist.  Just  as  in  other  joints,  dislocations  of  the  wrist 
are  rare  in  the  first  age  period.  Since  the  advent  of  the  x-ray 
many  so-called  dislocations  are  found  to  be  fractures,  and  the 
one  most  often  mistaken  in  this  age  period  is  the  epiphyseal 
separation  of  the  radius.  The  comparatively  few  dislocations 
that  do  occur  are  in  the  second  age  period, 
Fig.  167.  Dislocation  of  the  uhia  back- 
ward is  sometimes  seen. 

Dislocations  of  the  carpal  bones  at  the 
radial  articulation  or  at  midcarpal  arti- 
culation are  seen  very  rarely,  and  when 
they  do  occur  are  generally  associated 
with  fracture.  While  any  carpal  bone  may 
be  dislocated,  the  semilunar  is  the  one  by 
far  most  frequently  involved.  It  is  dis- 
located anteriorly  and  is  generally  rotated, 
so  that  the  radial  articulation  is  pointing 
backward,  Fig.  168. 

Hand.  Dislocation  of  the  thumb 
metacarpal  at  the  carpal  articulation  is  by 
far  the  most  common  of  the  metacarpal 
dislocations,  and  is  generally  back\\ard. 
While  the  other  metacarpals  may  be  dis- 
located, fractures  occur  much  more  fre- 
quently. Dislocations  of  the  phalanges 
(Fig.  169)  are  quite  common,  and  backward  dislocations  of 
the  first  phalanges,  especially  of  the  thumb,  are  the  most  fre- 
quent of  all. 

Pelvic  Bones.  Dislocations  oi  the  pelvic  bones  are 
quite  rare,  though  the  writers  have  seen  one  case  where  a 
blow  upon  the  sacrum  caused  a  complete  forward  dislocation. 
The  so-called  sacro-iliac  subluxations,  in  the  writers'  opinion, 
do  not  exist.  The  joint  is  of  the  saw-tooth  variety  and  before 
a  slipping  could  take  place  these  saw-tooth  edges  would  have  to 


Fig.  169. — Backward 
dislocation  of  the 
thumb  phalanx. 


■a  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   170. — Backward  dislocation  of  the  hip. 


ACQUIRED  DISLOCATIONS  153 


Fig.   171. —  Obturator  dislocation  of  the  hip. 


154  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

be   broken.   These   conditions   must   be   ligamentous   sprains. 

Hip.  Dislocations  of  the  hip  are  much  more  common  in 
the  male  than  in  the  female.  In  the  first  age  period,  except 
in  pathological  conditions,  dislocations  are  very  rare.  The 
epiphyseal  line  being  present,  injury  to  this  joint  causes  a 
separation  instead  of  the  tearing  of  the  capsule  followed  by 
a  dislocation. 

It  is  in  the  second  age  period  that  most  of  the  hip  dislocations 
occur  as  the  neck  of  the  femur  is  much  stronger  than  the 


K 

Fig.   172.  Fig.   173. 

Fig.  172. — Lateral  dislocation  of  the  patella. 

Fig.   173. — Subluxation  of  the  tibia,  due  to  an  old  tuberculous  process. 

capsule,  and  consequently  trauma  causes  the  capsule  to  tear, 
allowing  the  head  to  slip  out,  instead  of  producing  a  fracture 
of  the  neck.  Backward  dislocations  are  the  most  common 
(Fig.  170),  and  probably  dislocations  into  the  region  of  the 
obturator  foramen  are  next  in  frequency,  Fig.  171.  Besides 
these  two  groups  there  are  variations  of  each  one. 

In  the  third  age  period,  on  account  of  the  absorption  of 


ACQUIRED  DISLOCATIONS 


:>j 


the  lime  salts  with  a  resulting  brittleness  of  the  neck,  trauma 
will  cause  a  fracture  of  the  neck  instead  of  a  dislocation, 
though  occasionally  dislocations  are  seen  in  very  old  people. 

Patella.  Dislocations  of  the  patella  are  uncommon, 
though  w^hen  they  do  occur  they  are  cither  internal  or  external. 
Fig.  172.  ^ 

Knee.     Dislocation  of  the  knee  is  more  common  in  the 
male  than  in  the  female.  This  is  due  not  to  any  structural 
difference  in  the  knee,  but  to  the  fact  that  the  male  engages 
in  more  violent  pursuits  and 
hazardous    occupations.    Dis- 
locations of  the  knee  in  any 
case,   however,   are  very  un- 
common.    They  seldom  occur 
in  the  first  age  period,  due  to  the 
presence  of  the  epiphyses.  The 
cartilaginous  union  of  the  epi- 
physis is  weaker  than  the  cap- 
sule of  the  joint;  consequently 
in  injury  it  yields  instead  of 
the  capsule. 

Tibia.  In  the  second  age 
period  the  tibia  may  be  dis- 
located backward,  forward 
or  laterall}^  The  backward 
dislocation  is  probably  the 
most  common.  Complete 
lateral  dislocations  are  quite 
rare  without  fracture,  though 

slight  lateral  subluxation  is  frequently  seen  as  the  result  of 
bad  tearing  of  the  ligaments,  or  one  condyle  may  be  displaced 
laterally  in  a  longitudinal  fracture  through  the  joint. 

In  old  pathological  processes,  such  as  tuberculosis,  the 
contractions  of  the  muscles  combined  with  the  destruction  of 
the  articulating  surfaces  frequently  bring  about  a  posterior 
dislocation  of  the  tibia.  Fig.  173. 


Fig.   174. — Posterior  dislocation  of 
the  foot  with  fracture. 


156  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Dislocation  of  the  semilunar  cartilage  is  quite  a  common 
occurrence,  but  since  cartilage  does  not  cast  a  shadow  upon  the 
plate  it  cannot  be  demonstrated.  This  condition  is  often  asso- 
ciated with  fractures  of  the  tibial  spines,  and  when  this 
is  noted  one  should  also  be  suspicious  of  a  dislocated  cartilage. 
Fibula.  Dislocations  of  the  upper  end  of  the  fibula  from 
injuries  and  from  muscular  violence  have  been  reported,  but 

they  are  extremely 
uncommon.  The 
writers  have  never 
seen  such  a  case. 

Pathological 
dislocations,  such 
as  crushing  in- 
juries with  frac- 
ture of  the  head  of 
the  tibia,  or  non- 
growth  of  one  of 
the  bones,  are  oc- 
casionally found. 

Foot.  Dis- 
locations of  the 
foot  are  quite  common  (Fig.  174),  but  rarely  occur  in  the  first 
age  period,  as  in  that  period  the  epiphysis  yields  instead  of  the 
joint.  In  the  second  age  period  this  injury  is  most  frequent. 
The  foot  may  be  dislocated  backward  or  laterally.  It  is  often 
associated  with  a  Pott's  fracture.  Any  of  the  tarsal  bones  may 
be  dislocated,  but  dislocation  of  the  astragalus  is  most  com- 
mon. Dislocation  of  the  metatarsals  is  uncommon  without  frac- 
ture. The  first  is  the  one  most  commonly  involved.  Fig.  175. 
Dislocation  of  the  phalanges  of  the  feet  does  not  occur  as 
frequently  as  dislocation  of  these  bones  of  the  hands.  They 
are  generally  associated  with  fracture,  and,  as  they  usually 
result  from  crushing  injuries,  they  are  frequently  compound. 


Fig. 


175. — Dislocation   of  the    first    metatarsal. 
{Courtesy  of  Dr.  Henry  J.  Walton.) 


CHAPTER  yill 
BONE  INFECTIONS 


CHAPTER  VIII 
Bone  Infections 

THIS  chapter  will  be  devoted  to  the  discussion  of  those 
infections  that  primarily  involve  the  bone,  though  they 
may  simultaneously  or  later  involve  the  joint.  Osteo- 
myelitis is  the  most  important  and  frecjuent  of  these  infections. 
Osteomyelitis.  In  Chapter  II  on  Normal  Bone 
attention  was  called  to  the  constituent  parts  of  a  bone:  the 
periosteum,  cortex,  medullary  canal,  the  cancellous  heads 
and  the  cartilaginous  articulations.  Any  one  or  all  of  these 
structures  may  be  involved  in  an  inflammatory  process. 
When  the  periosteum  is  involved  w^e  have  a  periostitis;  when 
the  infection  is  confined  to  the  cortex  we  have  an  osteitis, 
and  when  the  medullary  canal  is  attacked  alone  we  speak 
of  a  myelitis.  The  combination  of  a  diseased  cortex  and 
medullary  canal  is  known  as  osteomyelitis.  While  the  pyogenic 
factors  may  vary  in  bone  infection,  the  process  is  the  same, 
varying  only  as  to  the  severity  and  duration  of  the  infection. 
Before  taking  up  the  changes  that  occur  it  is  well  to  bear 
in  mind  just  how  the  infection  reaches  the  bone,  as  the  picture 
varies  according  to  the  point  at  which  the  infection  starts. 
In  a  general  way  we  may  speak  of  four  portals  of  entry. 

1.  Infection,  hematogenous  or  lymphoid  in  origin,  carried 
directly  to  the  medullary  canal  by  means  of  the  nutrient 
canal. 

2.  Infection  lodging  beneath  the  periosteum. 

3.  Infection  arising  within  the  joint. 

4.  Infection  b}'  direct  inoculation,  as  in  wounds  and  com- 
pound fractures. 

In  the  first  group,  the  blood  or  lymph  suj^ply  carries  the 
infection  through  the  nutrient  canal  into  the  medullary 
canal;  and  since  this  is  filled  with  soft  marrow  fat  the  infection 

159 


i6o  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   1-6.  Fig.   177. 

Fig.   176. — Osteomyelitis  showing  in\oIvement  of  the    medullary   canal 

and  cortical  bone. 
Fig.   177. — Osteitis  with  an  extensive  periostitis. 


may  spread  easily  and  rapidly  up  and  down  the  canal,  and 
by  means  of  the  Haversian  canals  will  finally  involve  the 
dense  compact  cortical  bone.  Fig.  176.  In  this  condition  the 
changes  take  place  within  the  bone,  and  the  infection  works 
its  way  toward  the  periphery.  In  the  earlier  stages  the  cortex 
and  periosteum  are  not  involved. 

When  the  infection  lodges  beneath  the  periosteum  we  have 
both   it   and    the  bonv  cortex  involved.   Since  the  cortex  is 


BONE  INFECTIONS 


i6i 


Fig.   178. — Here  is  an  acute  infection  starting  in  the  joint  and  inxolving 

the  femur. 


i62  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


quite  dense  the  infection  spreads  more  easily  into  the  per- 
iosteum and  along  the  outside  of  the  shaft.  The  cortex  becomes 
infected  more  slowly  on  account  of  its  density,  and  the  spread 
of  the  disease  is  more  or  less  limited.  Consequently  the  medul- 


FiG.    i~9.  Fig.   i8o. 

Fig.    I  "9- — Compound  fracture  with  osteomyelitis. 

Fig.   i8o. — Osteomyelitis  with  sequestrum  l\ing  in  a  cavitj*. 

lary  canal  is  not  often  in\c)Kcd,  but  with  the  localized  osteitis 
we  may  have  an  extensive  periostitis,  Fig.  177. 

\\  hen  the  infection  starts  in  the  joint  we  have  extensive 
destruction  of  both  articulating  surfaces,  and  fmall}*  the 
disease  breaks  through  one  of  the  cartilaginous  surfaces  and 


BONE  INFECTIONS  163 

destroys  to  a  more  or  less  degree  the  head  of  the  bone  where 
the  cancellous  bone  is  present;  and  again  the  infection  ex- 
tends but  slowly  into  the  medullary  canal  proper.  Cartilage 
is  quite  resistent  to  infection,  and  it  is  only  the  more  virulent 
organisms,  such  as  streptococcus,  etc.,  that  produce  such 
conditions,  Fig.  178. 

In  compound  fractures  (Fig.  179)  the  infection  is  carried 
directly  to  the  medullary  cavity  and  raw,  exposed  bone  sur- 
faces, so  that  periosteum,  cortex  and  medullary  canal  may 
be  involved  simultaneously. 

The  question  naturally  arises:  "Does  osteomyelitis  give  us 
a  constant  roentgenological  picture?"  The  answer  must  be, 
"No,"  but  this  answer  may  be  qualified  by  stating  that  the 
pathologic  process  is  the  same,  varying  only  as  to  the  in- 
tensity and  duration  of  the  infection.  Hence,  if  we  understand 
the  fundamental  principles  of  bone  infection,  while  the  picture 
may  vary,  yet  the  condition  may  be  recognized.  Only  two 
changes  may  be  seen  upon  a  plate  upon  which  to  base  a  diag- 
nosis— bone  destruction  and  bone  production.  The  variation  in 
these  two  processes  constitutes  the  basis  of  a  diagnosis. 

Attention  has  been  called  to  the  fact  that  the  dense, 
compact  bone  is  pierced  by  numerous  small  Haversian  canals, 
and  that  these  are  in  direct  connection  with  the  medullary 
canal.  Now  an  infection  that  starts  in  the  medullary  canal 
not  only  extends  up  and  down,  but  also  enters  the  Haversian 
canals;  and  since  these  canals  extend  through  the  compact  bone 
and  have  numerous  intersections  the  roads  for  the  transporta- 
tion of  infection  are  already  prepared.  Between  these  canals 
w^e  have  dense  masses  of  calcium  salts  which,  relatively, 
are  but  slowly  absorbed  by  infection.  Thus  these  canals 
make  it  possible  for  the  infection  to  spread  and  break  out  in 
other  portions  of  the  bone,  frequently  leaving  normal  bone 
between  the  primary  focus  and  the  secondary  lesion,  as  the 
infection  may  have  failed  to  enter  all  the  canals  in  the  affected 
area.  Often  by  means  of  the  intersecting  canals  the  infection 


i64  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


may  completely  surround  an  area  of  bone  and  thus  dcxitalize 
it  and  form  what  is  known  as  a  sequestrum,  Fig.  i8o. 

Since  the  infection  is  at  first  confined   to  the   medullary 

canal  and  within  the  Haversian 
canals,  there  is  a  short  period 
of  time  when  the  canals  are 
filled  but  no  destruction  has 
taken  place.  This  is  important 
to  remember,  because,  as  has 
already  been  pointed  out,  the 
only  changes  visible  upon  a 
plate  are  bone  destruction  and 
bone  production;  so  there  is  a 
period  in  beginning  osteom^-e- 
litis  when  the  .v-ray  examina- 
tion will  show  a  perfectly  nor- 
mal bone.  Frequently  cases  of 
acute  osteomyelitis  have  been 
seen  in  the  first  ten  days  of  the 
infection,  where  there  were  ex- 
tensive swelling  and  inflamma- 
tion of  the  soft  tissues  surround- 
ing the  bone,  with  intense  pain 
and  high  temperature,  yet  the 


Fig. 


i8i. — A -ray  of  an  acute 
osteomyelitis  one  week  atter 
onset.  Operation  showed  the 
Haversian  canals  to  be  full  of 
pus,  but  since  breaking  down 
of  the  bone  tissue  had  not  oc- 
curred, the  A-ray  examination 
was  negative. 


A"-ray  examniation  was  nega- 
tive, Fig.  i8i.  Such  cases  at  operation  will  show  an  inflamed, 
infected  periosteum  and  the  canals  full  of  pus,  but  no  destruc- 
tion. Care  must  be  taken  in  such  cases  not  to  mislead  the 
surgeon  by  reporting  no  infection  present. 

When  the  infection  is  very  virulent  we  have  extensive 
destruction  and  but  little  new  bone  production,  while  in  the 
chronic  type  we  have  but  little  destruction  and  extensive 
bone  production,  Fig.  182. 

In  an  acute  osteomyelitis  we  get  the  following  picture  upon 
a  plate:  The  infection,  having  lodged  in  the  medullar}'  cavity, 
takes  the  path  of  least  resistance  and  extends  along  the  medul- 


BONE  INFECTIONS 


165 


lary  canal,  and  we  get  vacuolated  spaces  represented  by  areas 
of  lessened  density.  The  infection  now  spreads  to  the  bony 
cortex  and  travels  irregularly  by  means  of  the  Haversian 
canals,  so  that  there  are  areas 
of  bone  destruction  with  normal 
bone  in  between,  and  eventu- 
ally these  normal  areas  will  be 
cut  off  and  become  sequestra. 
This  is  an  important  point  of 
differential  diagnosis,  because 
every  pathological  process  in 
bone  must  be  viewed  as  a  pos- 
sible malignancy  until  proven 
otherwise.  Malignancy  in  long 
bones  starts  from  one  central 
point  and  radiates  equally  in 
all  directions,  absorbing  the 
bone  as  the  growth  advances, 
but  never  appears  as  separated 
areas  with  normal  bone  in  be- 
tween and  never  produces 
sequestra. 

The  osteomyelitic  infection 
will  finally  pierce  the  cortex  in 
one  or  more  places,  leaving 
areas  of  normal  cortex  between. 
Here  again  we  have  another 
important  point  of  differential 
diagnosis,  as  in  malignancy.  Fig.  182.— Chronic  osteomyelitis 
when  the   growth    reaches   the  showing    marked    new    bone 

cortex,  it  destroys  it  completely  formation     but    with    little 

T     T  J        ^   •  M.  destruction. 

as  a  whole  and  not  m  parts  as 

osteomyelitis  does. 

Thus  far  we  have  been  discussing  the  acute  destructive 
process;  but,  when  the  cortex  is  pierced  and  drainage  estab- 
lished,  nature,   with  the  acquired  resistance  of  the  tissues, 


[66  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   183.  Fig.   184. 

Fig.   183. — The  new  bone  formation  defines  the  boundaries  of  infection. 
Fig.    184. — Tlie   periosteal    new   bone   gives   the   appearance   of  a   shaft 

actually  expanded,  but  the  apparent  expansion  is  due  to  deposition 

of  bone  on  the  outside. 


BONE  INFECTIONS  167 

now  attempts  to  limit  the  destructive  process.  This  is  done  by 
building  up  a  new  bone  wall  at  the  edge  of  the  infection.  To 
produce  bone  reaction  there  must  be  stimulation,  and  the  point 
of  stimulation  has  to  be  at  the  point  where  the  infection  stops 
and  the  normal  bone  begins;  so  we  must  look  for  our  new  bone 
production  at  the  edges  of  the  infection  and  not  in  the  middle 
of  it.  The  result  of  this  will  be  that  the  new  bone  laid  down  will 
follow  the  edge  of  the  infection.  This  gives  us  a  varied  picture, 
as  the  boundaries  of  the  destructive  process  will  determine 
where  the  new  bone  will  be  laid  down,  Fig.  183.  At  the  same 
time,  since  the  infection  has  reached  the  periosteum,  we  shall 
find  extensive  periosteal  bone  following  the  course  of  the 
periosteum.  This  deposit  of  periosteal  bone  w^ill  frequently  be 
sufficiently  great  to  give  the  appearance  of  expansion  of  the 
bone,  Fig.  184.  Close  inspection,  however,  will  reveal  that  the 
apparent  expansion  is  in  reality  due  to  deposition  of  bone  on 
the  outside.  This,  too,  is  an  important  point,  as  benign  growths 
of  the  bone,  such  as  cysts  and  osteochondromata,  invariabh' 
expand  the  cortex  while  osteomyelitis  does  not. 

The  predominating  feature  in  acute  osteomj-elitis  is  bone 
destruction  with  but  little  new  bone  formation.  The  acute 
types  are  seen  most  frequently  in  the  young  and  in  early  adult 
life. 

In  chronic  osteomyelitis  the  conditions  are  just  reversed. 
We  have  excessive  bone  production  with  but  few  small  areas  of 
destruction.  The  entire  bone  is  thickened,  frequently  to  such 
an  extent  that  the  medullary  cavity  seems  to  be  obliterated. 
The  bone  is  often  irregular  in  shape  and  much  thickened,  due 
to  extensive  deposition  of  periosteal  bone  upon  the  cortex. 
In  the  bone  there  may  be  small  areas  of  absorption  due  to  focal 
spots  of  infection.  When  sequestra  are  present  they  are  usually 
very  small,  and,  on  account  of  the  surrounding  dense  bone, 
frequently  cannot  be  demonstrated  by  the  .v-ray.  Fig.  185. 
This  type  of  osteomyelitis  is  seen  more  frequently  in  middle 
and  old  age.  When  the  infection  starts  beneath  the  periosteum 
the  lesion  will  be  confined  to  the  cortex.  When  it  starts  in 


i68  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  joint  it  spreads  slowly  into  the  cancellous  head,  and  if 
untreated  will  reach  the  medullary  canal  and  then  spread 
rapidly. 

In  compound  fractures  the  infection  is  confined  to  the  ends 
of  the  bone  and  seldom  spreads,  as  bone  drainage  from  the 
infection  exists  through  the  open  wound. 


Fig.   185.  Fig.   186. 

Fig.     185. — Chronic    osteomyelitis    with    a    small    cavity    containing    a 

sequestrum. 
Fig.   186. — Vacuolated  area  in  the  head  of  the  radius,  known  as  Brody's 

abscess. 

In  a  certain  number  of  cases  we  shall  find  a  single  punched- 
out  area,  definitely  circumscribed,  situated  in  the  cancellous 
head  of  a  bone  about  a  half  inch  from  the  joint.  Such  a  locahzed 
osteomyelitis  we  speak  of  as  Brody's  abscess.  Fig.  186.  The 
upper  ends  of  the  tibia  and  humerus  seem  to  be  the  favorite 
locations  for  such  conditions. 

From  this  description  it  wilt  be  readily  seen  that  there  is  no 


BONE  INFECTIONS 


169 


Fig.  187. — A  most  atypical  tuberculosis  ol  the  shaft  of  the  radius  in  a 
patient  of  forty-five  years.  The  condition  was  not  diagnosed  until  a 
microscopic  examination  was  made  after  operation. 


i-o  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

one  definite  .v-ray  picture,  but  that  the  changes  will  depend 
entirely  upon  the  virulence  of  the  infection,  the  stage  of  the 
disease  and  the  resistance  of  the  patient. 

The  six  points  which  follow  should  always  be  carefully 
noted  upon  the  plate: 

1.  The  place  where  the  infection  starts. 

2.  The  character  of  the  destructive  process. 

3.  The  path  of  extension,  that  is,  spreading  in  all  directions 
or  following  the  path  of  least  resistance. 

4.  The  character  and  situation  of  the  new  bone  production. 

5.  The  condition  of  the  cortex,  whether  it  is  intact,  de- 
stroyed as  a  whole  or  pierced  by  sinuses,  expanded  or  unex- 
panded. 

6.  The  type  of  periosteal  reaction,  whether  it  is  parallel  or 
perpendicular  to  the  shaft. 

Thus  far  we  have  discussed  only  those  infections  arising 
from  pyogenic  organisms. 

Tuberculosis.  The  question  of  tuberculosis  as  an  osteo- 
myelitic  infection  has  been  much  discussed,  and  some  authori- 
ties state  that  it  is  much  more  frequent  than  is  commonly 
supposed.  In  the  writers'  experience  it  was  found  to  be  ex- 
tremely rare  in  adults,  onl}^  two  cases  having  been  encountered 
in  which  diagnosis  was  made  only  by  the  microscopical  exami- 
nation following  operation.  In  one  case  there  was  extensive 
destruction  of  the  shaft  of  the  ulna,  no  new  bone  formation, 
no  sequestrum,  and  the  cortex  was  expanded  just  as  in  a 
benign  growth.  Fig.  1 87. 

It  is  true  that  in  extensive  tuberculosis  of  the  joint,  the 
disease  penetrates  the  cartilage  of  one  of  the  articulating 
surfaces  and  involves  the  head  of  the  bone,  but  the  infection  is 
generally  limited  to  the  bone  beneath  the  cartilage  and  does 
not  extend  down  into  the  cancellous  bone  as  does  an  ordinary 
osteomyelitis.  Fig.  188.  There  is  no  new  bone  production,  no 
sequestrum  and  the  joint  is  always  involved. 

In  children,  however,  it  is  common  to  see  a  tuberculous 
dactylitis  which  may  involve  one  or  more  bones  accompanied 


BONE  INFECTIONS 


171 


by  a  marked  periostitis.  Occasionally  one  of  the  metacarpals 
or  phalanges  will  show  punched  out  areas  in  the  shaft  of  bone 
similar  to  cysts.  Lues  and  osteomyelitis  will  frequently  give 
the  same  appearance  upon  the  plate,  so  that  often  it  is  impos- 
sible to  differentiate  these  three  conditions  b}'  .\-ray  examina- 
tion, Fig.  189. 


Fig.  188. — Tuberculosis  of  one  side  of  the  epiphysis  of  the  tibia.  The 
disease  does  not  extend  do^\•n  into  the  cancellous  portion  of  the  bone 
beneath  the  epiphysis. 

Besides  the  tuberculous  dactjditis  in  children  we  occa- 
sionally see  tubercuh:)sis  of  the  shaft,  and  this  is  probably  more 
frequent  than  has  hitherto  been  supposed.  The  writers  have 
seen  five  such  cases  in  the  last  year.  These  lesions  generally 
start  at  or  just  behind  the  epiphyses  in  the  cancellous  bone  or 
medullary  canal.  The  bone  is  destroyed  just  as  in  ordinary 
osteomyelitis,  and  there  may  be  a  marked  periosteal  bone 
production  but  seldom  new  bone  in  the  shaft.  The  lesion  is 


172  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


frequently  multiple.  So  far,  from  the  few  cases  observed, 
it  has  seemed  impossible  to  differentiate  it  from  an  acute 
or  luetic  osteomyelitis.  In  the  tuberculous  types,  however,  the 


Fig.   189.  Fig.    190. 

Fig.   189. — Tuberculosis  of  the  first  metacarpal  with  marked  periostitis. 
Fig.   190. — Tuberculous  osteomyehtis  in  an  infant  with  sequestrum.  This 
cannot  be  differentiated  from  the  inflammatory  type  of  osteomyehtis. 

joint  is  frequently  involved  and  the  lesion  is  near  the  epiph3^sis. 
Fig.  190. 

Lues.  Lues,  while  attacking  practically  all  the  structures 
of  the  body,  seems  to  have  a  peculiar  afTinity  for  the  bones,  and 
the  congenital  and  acquired  forms  manifest  themselves  in  a 
variety  of  ways.  The  congenital  type  will  be  discussed  in  the 
chapter  on  "Joint  Lesions  of  Children."  The  acquired  form 
varies  from  a  slight  periostitis  to  an  advanced  osteomyelitis. 
Luetic  periostitis  is  probably  the  most  common  of  all  lesions, 
and  is  seen  most  often  in  the  last  half  of  the  second  and  all  of 
the  third  age  period.  It  may  involve  one  or  several  bones. The 
periostitis  is  generally  marked,  and  the  calcium  salts  are  laid 
do\Mi  more  or  less  parallel  to  the  long  bone  and  are  frequently 
raised  a  little  from  the  shaft.  This  type  cannot  be  differen- 
tiated from  the  inflammatory  type.  If  two  or  more  bones, 
however,  are  involved,  the  lesion  is  generallj'  luetic  in  origin, 
and  this  is  especially  true  if  it  is  accompanied  by  an  osteitis 


BONE  INFECTIONS 


1-3 


without  a  cavity,  Fig.  191.  Occasionally  the  calcium  salts  may 
be  laid  down  perpendicular  to  and  extending  out  from  the 
shaft  about  one  quarter  of  an  inch.  For  want  of  a  better  name 


Fig.   191.  FiG.   192. 

Fig.   191. — Luetic  periostitis,  showing  in\oKement  of  both  bones  ol  tlie 

forearm. 
Fig.   192. — Luetic  periostitis  (lace-work  type)  of  the  ulna. 

we  speak  of  this  as  the  "lace  work  type"  of  periostitis,  and 
when  this  is  present  it  is  invariably  luetic  in  origin.  Unfortu- 
nately this  type  is  the  exception  rather  than  the  rule,  Fig.  192. 
Luetic  osteomyelitis  produces  the  same  bone  changes  as 
the  inflammatory  type  and  frequently  cannot  be  differentiated. 


1-4  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


<jjH 

K 

IB 

^^mA 

^ 

^^l^^x 

^ 

^Vii^ 

imm^s 

There  are  two  points,  however, 
that  assist  us  in  making  a  cor- 
rect diagnosis.  First,  the  lesions 
are  frequently  multiple  and 
there  is  generally  more  bone 
production.  The  second  point 
is  very  important — the  clinical 
picture  does  not  coincide  with 
that  given  by  the  .v-ray.  In  lues 
the  plate  may  show  a  very 
acute  osteomyelitis  evidenced 
bv   extensive    destruction,    the 


Fig.  193. — Luetic  osteomyelitis 
without  swelling  of  the  soft 
tissues.     Few  clinical  signs. 

entire  bone  being  involved. 
\\  ith  such  a  plate  one  would 
expect  an  acutely  inflamed  part, 
verj^  tender  and  accompanied 
by  fever.  Instead  there  will  be 
but  few  clinical  signs,  only 
slight  tenderness,  no  fever  and 
practically  no  inflammation. 
Fig.  193. 

A  careful  study  of  the  plate 
will  give  not  only  a  correct 
diagnosis,  but  further  informa- 
tion to  the  surgeon.  It  shows 
not  only  the  extent  of  the  dis- 
ease and  the  presence  of  seques- 
tra, but  it  also  determines  the 
presence  or  absence  of  an  in- 
vokicrum.  This  is  of  great  im- 
portance, as  it  is  frequently  the 


Fig.  194. — Marked  involucrum 
with  the  entire  shaft  becom- 
ing a  sequestrum. 


BONE  INFECTIONS 


175 


determining  factor  as  to  the 
character  of  the  operation 
necessary.  For  example,  in  an 
acute  osteomyelitis,  where 
practically  the  whole  bone  is 
involved,  it  will  be  necessary 
to  take  away  the  entire  bone 
to  cure  the  patient.  Now,  if 
the  plate  shows  no  involucrum 
(Fig.  195)  the  surgeon  will 
confine  himself  to  opening  the 
bone  to  get  free  drainage,  and 
if  the  patient's  condition  re- 
mains good  the  radical  opera- 
tion will  be  delayed  until  the 
involucrum  has  formed.  Fig. 
194. 

Typhoid.  Typhoid  infec- 
tion takes  place  in  the  second 
age  period,  but  it  is  a  rather 
rare  condition.  The  spine  and 
ribs  are  most  frequently  in- 
volved, occasionall}^  the  long 
bones,  Fig.  196.  When  the 
spine  is  involved  the  margin 
of  one  vertebra  is  attacked 
close  to  the  cartilaginous  disc. 
The  destructive  process  may 
destroy  the  entire  disc,  and 
when  repair  takes  place  there 
is  marked  new  bone  produc- 
tion and  sometimes  actual 
ankylosis.  The  writers  have 
seen  one  case  in  which  the 
mandible  w^as  involved.  The 
plateshowed  around  punched- 


Ik;.  195. — An  acute  o^tcduixtlitis 
with  no  involucrum  but  very  slight 
deposition  in  the  periosteum. 


1-6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

out  area,  sharply  circumscribed;  a  dense  calcium  deposit 
surrounded  the  infection,  indicating  that  the  lesion  was  a 
very  chronic  and  inactive  process.  Occasionally  we  may  have 
a  periostitis  of  the  long  bones,  but  it  cannot  be  distinguished 
on  the  plate  from  the  ordinary  inflammatory  types. 

Actinomycosis.     Actinomycosis   usually   affects    the    jaw 


Fig.   196. — A    typhoid    periostitis    with    a    cavity    in    the    cortex. 

and  produces  a  chronic  osteomyelitis,  ^^  ith  no  special  character- 
istics which  make  a  differential  diagnosis  possible  by  .v-ray. 

Raynaud's  Disease.     In  Raynaud's  disease  (Fig.  197)  the 
terminal  phalanges  are  involved.  Bone  atrophy  and  marked 


BONE  INFECTIONS 


177 


thinning  are  present  giving  a  spearlike  appearance;  finally  the 
entire  phalanx  maj'  be  entirely  absorbed.  The  lesion  is  gener- 
ally confined  to  the  terminal  phalanges.  Occasionally  the  same 
changes  are  seen  in  endarteritis  obliterans.  In  dry  gangrene 
there  is  a  gradual  absorption  of  the  phalanges. 

Leprosy.     Leprosy  (Figs.   198,   199)  is  characterized  by  a 


Fig.   197. — Raynaud's  disease,  showing  the  spearhke  appearance  of  the 

terminal  phalanges. 


progressive  atrophy  starting  in  the  terminal  phalanges  and 
gradually  extending  backward,  involving  all  the  phalanges. 
There  is  a  gradual  absorption  of  the  bone  so  that  it  eventually 
completely  disappears. 

CocciDOiDAL  Granuloma.  Coccidoidal  granuloma  (Figs. 
200,  201,  202),  is  due  to  a  parasitic  organism  involving  the 
bones,  joints  and  soft  tissues.  The  .v-ray  appearance  of  a  joint 
is^  essentially  that  of  tuberculosis,  namely,  a  marked  haziness 
of  the  joint,  atrophy  and  destruction  of  the  articulating  sur- 


12 


1-8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.   198. — Leprosy.  (Courtesy  of  Dr.  W.  B.  Bowman.) 


Fig.   199. — Leprosy.  (Courtesy  oj  Dr.  W.  B.  Bowman.) 


BONE  INFECTIONS 


1-9 


Fig.  200. — Coccidoidal  granuloma.  {Courtesy  oj  Dr.  ]V.  B.  Buwmaii.) 


Ww'      ^^ 

'^  »  "*      A 

i     J 

% 

f 

Fig.  201. — Coccidoidal  granuloma.      Fic.    202. — Coccidoidal    granuloma. 
{Courtesy  0/  Dr.  W  .  B.  Bouman.) 


i8o  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

faces  with  no  bone  production.  The  infection  extends  into  the 
bones  adjacent  to  the  joint,  and  here  we  get  the  same  destruc- 
tive process  as  in  the  joint  with  no  new  bone  production.  The 
bony  involvement  is  generally  more  extensive  than  in  tuber- 
culosis but  the.v-ray  picture  is  so  nearly  like  that  of  tuberculosis 
that  it  is  impossible  to  differentiate  these  lesions. 

Mineral  Poisoning.  Occasionally  one  sees  bone  infec- 
tions resulting  from  mineral  poisons,  for  example,  phosphorus 
poisoning  where  the  mandible  is  involved.  The  changes  in  this 
instance  are  the  same  as  in  chronic  pyogenic  infections. 

Special  Infections.  Besides  the  types  noted  above,  we 
have  bone  infections  which  are  limited  to  certain  bones  hav- 
ing specific  functions,  such  as  abscesses  confined  to  the  alveolar 
portion  of  mandible  and  maxilla  surrounding  the  apices  of 
teeth,  or  to  the  destruction  of  mastoid  cells  in  mastoiditis. 
These  infections  are  not  within  the  scope  of  this  book  and 
will  not  be  discussed. 

\\  e  have  emphasized  the  fact  that  our  diagnosis  is  based 
upon  bone  destruction  and  production  arising  from  the  infec- 
tion. If  any  other  cause  has  been  added  to  the  infection, 
particularly  surgical  interference,  we  may  draw  erroneous 
conclusions,  because  our  apparent  bone  destruction  as  seen  upon 
the  plate  may  not  be  due  to  disease,  but  may  be  the  result  of 
the  surgeon's  curette.  Furthermore  our  new  bone  production 
may  take  place  in  the  normal  bone  through  which  the  sur- 
geon has  passed  to  reach  the  infection.  Before  attempting  an 
.v-ray  diagnosis  of  any  bone  lesion,  it  is  always  well  to  know 
whether  there  has  been  surgical  interference.  One  should  be 
extremely  guarded  in  such  cases  in  making  a  diagnosis. 


CHAPTER  IX 
JOINT  LESIONS  IN  CHILDREN 


CHAPTER  IX 
Joint  Lesions  in  Children 

THE  lesions  treated  of  in  this  chapter  are  confined  to  the 
first  age  period.  The  vast  majority  of  joint  lesions  oc- 
curring in  this  period  can  be  classified  in  three  groups: 

1.  Those  occurring  from  birth  up  to  three  years. 

2.  Those  occurring  from  three  years  up  to  seven  years. 

3.  Those  occurring  from  seven  years  up  to  the  second  age 
period. 

In  the  first  class,  during  the  period  from  birth  up  to  one 
year,  tuberculous  infections  are  so  infrequent  that  they  can  be 
practically  disregarded.  After  one  year,  while  tuberculous 
infections  occur,  they  do  not  begin  to  appear  with  any  degree  of 
frequency  until  the  third  year.  In  the  same  way  acute  epi- 
physitis, while  probably  more  frequent  than  tuberculosis, 
follows  approximately  the  same  course. 

In  this  group,  especially  during  the  first  two  years,  joint 
changes  are  very  largel}^  confined  to  the  lesions  arising  from 
rickets,  congenital  lues  and  scurvy. 

In  the  second  group  period  the  three  most  common  lesions 
of  the  first  group  have  practically  disappeared,  to  be  replaced 
by  the  lesions  of  tuberculosis  and  acute  non-tuberculous 
infections. 

The  third  group  period  is  subject  to  the  same  lesions  as 
group  two,  with  one  other  added,  namel}-,  Perthes's  disease. 
In  the  latter  part  of  this  group  period,  just  before  puberty, 
Perthes's  disease  ceases  to  occur,  and  tuberculosis  is  the  pre- 
dominant lesion. 

It  must  be  remembered  that  this  age  classification  is  only 
approximate,  and  the  periods  may  easily  overlap. 

Rickets.  Now  the  changes  that  take  place  \n  ith  the  lesions 
in  the  first  group  period  w  ill  be  considered.  Since  rickets  is  bv  far 

183  ■ 


i84  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  most  common  of  all  joint  lesions  it  will  be  taken  up  first. 
Its  lesions  must  be  studied  from  two  standpoints;  first,  the 
changes  that  affect  the  joint,  and  secondly,  those  affecting 
the  bones,  which  may  be  considered  as  remote  or  constitutional 
changes. 


Fig.  203.  Fig.  204. 

Fig.  203. — The  saucer-shaped  expansion   of  the  epiphyses  of  the   radius 

and  ulna  in  rickets,  and  bowing  of  the  shaft  due  to  softenmg  of  the 

bone. 
Fig.  204. — The    saucer-shaped    expansion    of    the    epiphyses    in    rickets. 


In  the  joint  changes  the  first  thing  to  be  noted  is  that  the 
lesion  does  not  involve  one  joint  alone  but  is  invariably  mul- 
tiple. Fluid  may  be  present,  and  there  is  more  or  less  swelling 
of  the  periarticular  tissues.  The  cartilaginous  surfaces  of  the 
joint  are  intact,  but  there  is  marked  disturbance  of  the  epi- 
physeal line.  The  epiphj  seal  line  becomes  softened  and  has  a 
tendency  to  spread  out,  so  that  the  bone  at  that  point  is 


JOINT  LESIONS  IN  CHILDREN  185 

actually  wider  than  normal.  There  is  slight  condensation  of  the 
calcium  salts  at  the  epiphyseal  line,  and  the  end  of  the  bone  has 
an  inverted  saucer-shaped  appearance,  Figs.  203  and  204.  The 
epiphysis  proper  does  not  seem  to  be  disturbed;  the  changes  are 
confined  entirely  to  the  epiphyseal  hne.  This  saucer-shaped 


Fig.  205.  Fig.  206. 

Fig.  205. — Showing  the  saucer-shaped  epiphyses  of  tibia  and  fibula  with 

atrophy  of  the  bones  and  no  periostitis. 

Fig.  206. — Since  the  pressure  is  not  perpenclicuhir  to  the  epiphysis  ol  the 

upper  end  of  the  femur  the  rachitic  changes  tliere  are  atypicah 


expansion  is  most  marked  where  the  stress  and  strain  is 
directed  perpendicular  to  the  epiphyseal  Vine,  as  in  the  epi- 
physeal changes  in  the  tibia  and  radius,  Fig.  205.  In  the  hip 
and  shoulder,  where  the  stress  and  strain  are  not  directed 
perpendicular  to  the  epiphyseal  line  the  changes  are  not  so 
typical.  Fig.  206. 


i86  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Since  these  joints  are  swollen  and  painful,  there  is  limitation 
of  motion,  and  consequently  we  get  a  general  atrophy  of  the 

bones,  not  only  due  to  disuse  but 
also  due  to  the  fact  that  the  dis- 
ease is  a  nutritional  one.  W  hen 
the  attack  is  especially  severe  and 
of  long  standing  the  atrophy  be- 
comes so  extreme  that  the  bones 
lose  almost  all  of  their  inorganic 
salts  and  become  so  weakened 
that  the  slightest  trauma  will  pro- 
duce fractures.  In  severe  cases 
multiple  fractures  are  quite  com- 
mon, Fig.  20".  The  writers  have 
seen  one  case  in  which  there  were 
eighteen  fractures  of  the  long 
bones,  one  bone,  the  femur,  hav- 
ing four  distinct  fractures.  On  ac- 
count of  the  extreme  atrophy  we 
do  not  as  a  rule  have  periostitis, 
though  occasionally  it  may  be 
present  to  a  slight  degree.  Care 
must  be  taken  not  to  mistake 
this  condition  for  osteogenesis 
imperfecta.  In  this  disease  the 
marked  atrophy  and  the  multiple 
fractures  are  present  but  the  point 
of  differential  diagnosis  rests  upon 
the  fact  that  there  are  no  joint 
and  epiphyseal  changes. 

In    rachitic    conditions    it    is 


Fig.  207. — The  marked  atrophy 
of  the  bones  in  rickets  is  a 
frequent  cause  of  muhiple 
fractures,  where  there  is  no 
history  of  trauma.  Note  the 
fracture  in  the  radius  and 
■  ulna  with  some  callus  forma- 
tion. In  this  patient  all  the 
long   bones    had    sustained 

always  well  to  examine  the  chest, 
as  in  typical  cases  the  rosary  at  the  ends  of  the  ribs  will  be 
found,  due  to  the  same  saucer-shaped  expansion  of  the 
epiphyseal  line  of  the  ribs.  We  have  spoken  of  the  softening 

of  the  bones  due  to  the  absorption  of  the  calcium  salts.  This 


JOINT  LESIONS  IN  CHILDREN 


187 


same   change   takes   place   at   the  costochondral   ref^iDii    and 
produces   secondary   changes    in    the    bones    that    materially 


Fig.  208. — Atalcctatic  strips  of  consolidation  parallel  to  the  sternum  m 
rickets  resulting  from  the  sinking  in  of  the  costochondral  portion  of 
the  ribs. 


affect  the  pidnTonary  structures.  With  the  softening  at  the 
costochondral  region,  coupled  with  muscular  pull,  the  atmos- 
pheric pressure  on  the  outside  and  negative  pressure  within 
the  thorax,  the  sternum  and  cartilaginous  portions  of  the 
ribs  sink  in  and  produce  the  topical  "pigeon  breast"  of  rickets. 
The  deformity  may  be  so  marked  that  the  depressed  bony 


i88  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

structure  may  actually  rest  upon  the  roots  of  the  lungs  and 
interfere  materially  with  the  proper  aeration  of  the  king 
fields.  It  is  not  uncommon  in  cases  of  marked  rickets  to  see 
a  narrow  band  of  consolidation  just  beneath  the  costochondral 
junction  on  each  side  of  and  parallel  to  the  sternum.  This 
consolidation  is  in  reality  an  atelectatic  strip  (Fig.  208)  of 
lung  produced  by  pressure  and  when  this  is  present  to  a 
marked  degree  the  result  is  generally  fatal.  In  less  severe 
cases  faulty  aeration  is  quite  a  factor  in  the  production  of 
various  pulmonary  lesions.  With  proper  treatment  the  epi- 
physeal changes  clear  up,  but  there  is  frequently  left  behind 
a  line  of  slightly  condensed  lime  salts  extending  across  the 
shaft  of  bone  due  to  faulty  calcification  of  the  epiphysis. 
In  a  number  of  cases  four  or  five  such  lines,  parallel  to  each 
other  and  only  a  short  distance  apart,  have  been  observed, 
indicating  that  there  had  been  that  number  of  acute  exacer- 
bations in  the  course  of  the  disease.  Fig.  209.  With  the  softening 
of  the  bones  deformities  ensue.  The  most  characteristic  of 
these  are  the  pigeon  breast  deformity  and  the  saber  chin.  The 
deformities,  of  course,  persist  and  do  not  clear  up. 

To  summarize  the  chief  points  to  be  observed  in  rickets: 

1.  Disease  occurs  in  the  very  young,  especially  during  the 
first  two  years. 

2.  The  joint  is  intact,  the  epiphyseal  line  softened,  and 
spread  out  (saucer  shape). 

3.  Atrophy  is  present  with  frequent  occurrence  of  fractures. 

4.  Periostitis  generally  is  absent,  though  occasionally 
present. 

5.  Marked  pulmonary  changes  are  present. 

6.  Deformities  of  the  bones  are  noticeable. 

7.  No  subperiosteal  hemorrhages  exist. 

Congenital  Lues.  Just  as  in  rickets,  congenital  lues 
is  accompanied  by  bone  and  joint  changes.  The  joint  involve- 
ment is  generally  multiple,  and  there  is  periarticular  swelling. 
The  cartilaginous  surfaces  of  the  joint  are  intact,  but  as  in 
rickets  there  are  marked  disturbances  in  the  epiphyseal  zone 


JOINT  LESIONS  IN  CHILDREN 


189 


region.  Here  the  changes  take  place  partly  in  the  epiphyseal 
line  and  partly  upon  the  diaphyseal  side  of  the  epiphyseal 
line.  There  is,  however,  no  softening  or  saucer-like  expansion 
of   the    epiphyseal    line.    Instead,    the   process    is    distinctly 


Fig.  209.  Fig.  210. 

Fig.  209. — The  dark  line  about  one  inch  above  the  lower  epiphysis  of  the 
tibia  showing  that  there  was  a  rachitic  condition  present  when  the 
epiphysis  was  at  that  point.  This  dark  hne  was  due  to  faulty  calcili- 
cation  at  the  time  of  the  lesion. 

Fig.  210. — Destruction  of  the  upper  end  of  the  tibia  and  fibula,  due  to 
congenital  hies.  The  diaphyseal  portion  of  the  bone,  just  beneath 
the  epiphysis,  is  involved.  Note  that  there  is  no  spreading  out  of  the 
epiphysis. 

a  destructive  one.  There  are  localized  areas  of  softening  and 
destruction  just  beneath  the  periosteum  at  the  point  where 
the  periosteum  stops  and  the  cartilage  of  the  joint  begins. 
Fig.  210.  These  areas  of  destruction   are  circumscribed  and 


iQO  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


punched  out,  suggesting  the  appearance  of  having  been  bitten 
out  by  a  rongeur  forceps.  They  start  at  the  epiphyseal  line 
and  extend  back  into  the  bone  proper.  The  epiphyseal  line  in 
the  undestroyed  portions  appears  perfectly  normal. 

Atrophy  is  generally 
absent;  therefore,  frac- 
tures seldom  occur.  Luetic 
infections  nearly  always 
prockice  new  bone,  so  that 
there  is  practically  always 
more  or  less  periostitis, 
Fig.  211.  Since  there  is  no 
softening  of  the  bones,  de- 
formities do  not  occur  in 
the  long  bones;  and  for  the 
same  reason,  deformities 
are  absent  in  the  chest, 
hence  there  are  no  pulmo- 
nary    complications. 

To  summarize  the  chief 
points  characteristic  of  con- 
genital lues: 

1 .  The  disease  occurs  in 
the  very  young,  especially 
during  the  first  two  years. 

2.  The  joint  is  intact; 
there  is  no  spreading  out 
of  the  epiphyseal  line,  but 
gouged  out  areas  are  pre- 
sent in  the  diaphysis. 

3.  No    atrophy    takes 
place,  consequently  fractures  occur  but  seldom. 

4.  Periostitis  is  practically  always  present  and  generally 
excessive. 

5.  No  pulmonary  changes  are  present. 

6.  No  deformities  are  present. 


Fig.  211. — Note  the  marked  periostitis 
generally  present  in  congenital  lues. 


JOINT  LESIONS  IN  CHILDREN 


191 


7.  No  periosteal  hemorrhages  exist. 

Since  rickets  and  lues  are  seen  so  commonly  in  the  lower 
walks  of  life,  the  two  conditions  are  frequently  associated  in 
the  same  individual,   and   it   is   often   diflicult   to   determine 


Fig.  212.  Fig.  213. 

Fig.  212. — Triimmer  zone  of  destruction  behind  the  epiphyseal  hne  seen  in 

scurvy. 
Fig.  213. — Note  the  elevation  of  the  periosteum  with  an  organized  hemor- 
rhage beneath  so  frequently  seen  in  scurvy.  A  Triimmer  zone  is  also 
present. 


from  an  x-ray  plate  which  is  the  predominating!;  factor  in  the 
case. 

Scurvy.  As  in  kies  and  rickets,  this  disease  is  always 
characterized  by  joint  and  bone  changes.  The  joint  involve- 
ment is  generally  multiple.  Periarticular  swelling  is  usually 
present.  The  cartilaginous  surfaces  of  the  joint  are  intact, 
but  as  in  rickets  and  lues  there  are  marked  disturbances  in 
the  zone  of  the  epiphyseal  line.  All  the  changes,  however, 
take  place  upon  the  diaphyseal  side  of  the  epiphyseal  line. 
The  epiphysis  and  epiphyseal  lines  are  intact,  no  changes 
taking  place  at  all  in  these  two  structures.  There  is  no  saucer- 
shaped  expansion  of  the  ends  of  the  bone  as  in  rickets,  nor 


192  INJURIES  AND  DISEASES  OF  EONES  AND  JOINTS 

localized  areas  of  softening  and  destruction  as  in  lues.  Just 
behind  the  epiphyseal  line  at  a  distance  of  three  or  four  milli- 
meters is  what  looks  like  a  second  epiphyseal  line,  in  reality 


Fig.  214. — A   large   hemorrhage   beneath   the   torn-up   periosteum   which 
is  just  beginning  to  organize. 

a  band  of  localized  destruction  about  two  millimeters  in 
diameter  extending  through  the  entire  bone  and  parallel  to  the 
epiphyseal  line.  The  edges  of  this  band  are  denser  than  normal 
bone  and  give  the  appearance  of  eburnated  bone,  being  due 
probably  to  condensation  of  calcium  salts. This  band  (Triimmer 
zone)  produces  an  appearance  on  the  plate  as  if  a  surgeon 


JOINT  LESIONS  IN  CHILDREN 


193 


had  operated  and  remox  cd  a  narrow  cross  section  of  bone, 
Figs.  212  and  213.  Atrophy  may  be  present,  but  as  a  rule 
the  bone  texture   appears   normal.  Fractures  are  infrequent. 


Fig.  215. — Huge  ossifying  hematoma  in  seurvy.  Note  tlie  ossification  in 
the  periosteum  with  organization  of  the  hemorrliage.  This  tumor  was 
so  dense  that  it  was  mistaken  \ov  a  sarcoma.  The  .v-ray  examination 
showed  it  to  be  an  ossilying  hematoma. 

Periostitis  is  practically  always  present,  and  it  is  quite  common 
to  have  hemorrhages  beneath  the  periosteum.  It  has  already 
been  mentioned  that  in  children  the  periosteum  is  but  loosely 
attached  to  the  shaft  of  the  bone  but  is  firmly  adherent  at  the 

13 


194  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

epiphysis;  consequently  when  hemorrhages  occur  the  perios- 
teum is  ver}'  easih^  elevated  and  the  hemorrhage  surrounds 
the  entire  bone,  frequently  extending  to  the  epiphyseal  line. 
In  the  beginning  this  cannot  be  demonstrated  upon  a  plate, 
but  soon  organization  takes  place  and  calcium  is  deposited 
not  only  in  the  periosteum  but  also  in  the  blood  clot.  In 
excessive  hemorrhage  the  pressure  may  be  so  great  as  actually 
to  dislocate  one  of  the  epiphyses. 

When  organization  of  the  clot  has  taken  place  the  mass 
becomes  so  hard  and  dense  that  the  condition  may  be  mistaken 
for  sarcoma,  Figs.  214  and  215.  The  writers  have  seen  two 
such  instances  where  amputation  of  the  leg  was  advised,  and 
the  true  nature  of  the  condition  was  only  disclosed  by  the 
A-ray  examination.  The  mistake  in  diagnosis  may  occur  espe- 
cially after  the  acute  scorbutic  symptoms  have  subsided. 
The  A-ray,  however,  is  so  definite  that  once  seen  a  mistake  in 
diagnosis  will  rarely  be  made. 

To  summarize  the  chief  points: 

1.  Disease  occurs  in  the  very  young,  generally  in  the  first 
and  second  years. 

2.  The  joint  is  intact.  The  epiphysis  and  epiphyseal  line 
are  not  disturbed,  but  a  destructive  zone  is  formed  just  behind 
the  epiphyseal  line. 

3.  Atrophy  is  occasionally  present.  Fractures  are  infre- 
quent; the  epiphysis  is  occasionally  dislocated  bv  hemorrhage. 

4.  Periostitis  is  practically  always  present. 

5.  No  pulmonary  changes  are  present. 

6.  No  deformities  but  occasional  tumor  masses  are  present 
due  to  hemorrhage. 

7.  Subperiosteal  hemorrhage  is  frequently  present. 

It  will  be  noted  that  these  three  diseases,  namely,  rickets, 
congenital  lues  and  scurvy,  all  occur  at  approximately  the 
same  age,  that  all  have  multiple  joint  involvement,  and  that 
the  joint  surfaces  are  intact.  The  differential  points  in  diagnosis 
depend  upon  changes  in  and  around  the  epiphyseal  line  and  the 
character  of  the  periosteal  changes. 


JOINT  LESIONS  IN  CHILDREN  195 

In  rickets  the  changes  are  confined  to  the  epiphyseal  line; 
in  lues  the  epiphyseal  line  and  bone  behind  it  are  involved; 
while  in  scurvy  the  epiphyseal  line  is  intact  and  all  the  changes, 
comprised  in  a  zone  of  destruction,  take  place  just  behind  the 
epiphyseal  line. 

In  rickets  there  is  seldom  periostitis;  in  lues  there  is  marked 
periostitis,  while  in  scurvy  the  periostitis  is  frequently  accom- 
panied by  subperiosteal  hemorrhages.  In  rickets  we  have 
atrophy  and  frequently  multiple  fractures;  while  in  lues  and 
scurvy  there  is  generally  but  slight  atrophy,  and  there  are  no 
fractures. 

The  changes  that  have  been  described  apply  only  to 
untreated  cases.  When  certain  agents  are  administered  in 
rickets,  notably  cod-liver  oil,  as  has  been  pointed  out  by 
Howland  and  Park,  there  are  marked  metabolic  changes  not 
only  at  the  epiphyseal  line  but  also  in  the  periosteum.  The 
calcium  salts  are  deposited  in  the  cartilaginous  spiphysis. 
Since  this  is  not  a  direct  continuation  of  the  bony  otructure, 
but  is  laid  down  about  one-fourth  inch  from  the  bone  proper, 
the  roentgenogram  gives  a  clear  cartihiginous  space  between, 
suggesting  a  Triimmer  zone  such  as  is  seen  in  scurvy.  The 
epiphyseal  line,  however,  is  still  slightly  curved  and  expanded 
Figs.  216  and  217.  There  will  also  be  a  deposit  of  calcium 
salts  in  the  periosteum.  This  is  not  a  periostitis  in  the  ordinary 
sense,  since  it  is  not  an  inflammatory  process,  but  must  be 
looked   upon   as   an   atypical   periosteal    reaction,    Fig.    218. 

As  the  close  of  this  group  period  is  approached,  tuberculosis 
and  acute  epiphysitis  become  more  frequent  and  practically 
supplant  rickets,  congenital  lues  and  scurvy  in  the  second 
group  period. 

Tuberculosis.  In  this  infection  the  lesion  is  generally 
confined  to  one  joint.  As  has  been  so  frequently  noted,  bone 
destruction  and  production  are  essential  for  the  determination 
of  a  lesion;  consequently  there  is  an  indeterminate  stage  in 
tuberculosis  when  destruction  has  not  begun  and  when  only 
some  fluid  and  periarticular  swelling  of  the  joint  have  appeared. 


196  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


This  change  is  not  pathognomonic,  as  exactly  the  same  con- 
dition may  result  from  a  ligamentous  tearing.  The  roentgeno- 
grams of  the  joint,  however,  soon  become  very  hazy  and 
indistinct,  and  this  is  quite  typical  of  a  tuberculous  lesion. 
The    cartilage    is    gradually    destroyed;    and    while    cartilage 


Fig.  2i6.  Fig.  217. 

Fig.  216. — This  case  simulates  scurvy  in  that  there  is  an  apparent  Triimmer 
zone  present.  The  saucer-shaped  expansion  sho^^■s  that  this  is  a  case 
of  rickets  and  this  irregular  deposition  of  salts  in  these  epiphyses  is 
due  to  cod-liver  oil  feeding. 
Fig.  217. — Rickets  after  cod-liver  oil  feeding.  Note  the  dense  deposition  of 
lime  salts  at  the  epiphyses. 

cannot  be  demonstrated  by  means  of  the  .v-ray,  it  can  be 
determined  that  destruction  of  cartilage  has  taken  place  by 
the  fact  that  the  joint  space  has  become  narrowed.  The  disease, 
having  destroyed  the  cartilage,  penetrates  the  bone,  and  the 
bone  just  beneath  the  cartilage  becomes  irregular  and  worm- 
eaten.  Both  articulating  surfaces  are  involved;  on  account  of 
the  pain  the  joint  does  not  function,  and  atrophy  results,  in- 


JOINT  LESIONS  IN  CHILDREN 


197 


creasing  with  the  duration  of  the  disease,  Fig.  219.  The 
destruction  of  the  ends  of  the  bone  is  by  direct  extension  of 
the  infection,  never  by  metastases  to  other  parts  of  the  bone 
leaving  normal  bone  between.  As  the  disease  progresses  there 
is  frequently  subluxation  or  marked  distortion  of  the  joint. 


Fig.  218. — Healed  rickets  after  cod-liver  oil  feeding.  Note  that  in  these 
cases  there  is  invariably  calcification  of  the  periosteum  \\  hich  does 
not  indicate  an  inflammatory  process  such  as  is  seen  \\  ith  infection. 

When  the  disease  subsides  and  rej^air  takes  place,  unlike 
other  infections,  there  is  seldom  new  bone  production.  Instead, 
nature  replaces  the  destroyed  areas  by  fibrous  tissue,  and 
when  ankylosis  ensues  it  is  generally  fibrous  in  character. 
When,  however,  such  a  joint  goes  on  to  sinus  formation,  then 
a  different  condition  takes  place.  Since  these  sinuses  extend 


198  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

through  the  skin,  a  new  channel  is  opened  for  infection,  by 
means  of  which  some  pyogenic  organism  generally  reaches 
the  joint.  After  such  an  infection  takes  place  and  subsides 
we  then  have  bone  production,  sometimes  so  extensive  in 
character  as  completely  to  mask  the  changes  that  are  char- 


■M 


Fig.  219. — Tuberculosis  of  the  knee  joint  showing  marked  hazing  of  the 
joint  and  atrophy  with  some  destruction  of  the  epiphyses.  In  tuber- 
culous joints  the  diseased  portion  is  always  indistinct,  due  to  the  char- 
acter of  the  disease,  and  the  sweUing  of  the  soft  tissues  in  marked  dis- 
tinction to  the  detail  discernible  in  the  bone  above  and  below  the  joint. 


acteristic  of  tuberculosis.  It  is  important  to  remember,  then, 
that  mixed  infections  will  produce  new  bone  in  an  infected 
tuberculous  joint. 

Cases  of  tuberculosis  of  the  bones  have  been  discussed  in 
the  chapter  on  osteomyelitis.  ' 


JOINT  LESIONS  IN  CHILDREN 


199 


Acute  Epiphysitis — Non-tuberculous  (Fig.  220).  In 
the  early  stages  of  this  infection,  as  in  tuberculosis,  swelling 
and  fluid  are  present;  at  this  stage  it  is  impossible  to  dilleren- 
tiate  the  two  conditions.  As  the  disease  progresses  destruction 
appears,  but  generally  the  picture  of  the  joint  is  sharp  and 


Fig.  220. — Non-tuherculous  mtection  starting  in  the  shalt  ol  the  lemur 
and  extending  to  the  hip  joint.  Note  the  new  i^one  production.  The 
original  sinus  in  the  shaft  is  injected  with  bismuth.  New  bone  pro- 
duction is  not  seen  in  a  straight  tuberculous  infection. 


clean-cut,  not  hazy  and  indistinct  as  in  tuberculosis.  As  a  rule 
the  lesion  is  confined  to  one  joint,  though  it  may  be  multiple 
and  the  destruction  is  more  rapid  and  the  direct  extension 
more  irregular.  There  appear  frequently  focal  spots  of  disease 
in  the  bone  not  directly  connected  with  the  primary  infection 
of  the  joint.  As  the  disease  subsides  there  is  marked  production 


200  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

of  new  bone,  and  the  ankylosis  is  practically  ahvaj^s  bony 
in  character.  When  such  a  joint  is  examined  some  time  after 
the  lesion  is  cured,  one  is  struck  by  the  extensive  bone  produc- 
tion. In  this  lesion,  wherever  cartilage  is  destroyed  the  replaced 
tissue  is  always  bony  in  character,  while  in  tuberculosis  the 
destroyed  area  is  replaced  by  fibrous  tissue. 


Fig.  221. — Juvenile  deforming  osteochondritis.  {Perthes' s  disease.)  Early 
case  showing  slight  flattening  of  the  epiphysis  and  shght  thickening 
of  the  neck  of  the  femur. 


To  brief!}'  summarize:  It  will  be  noted  that  in  the  early 
stages  of  these  two  lesions  it  is  frequently  impossible  to  make  a 
differential  diagnosis,  but  when  the  stage  of  repair  has  been 
reached  the  presence  of  marked  production  of  new  bone 
indicates  that  the  infection  was  pyogenic  and  not  tuberculous. 

In  this  and  the  succeeding  group  periods  joints  will  occa- 
sionally be  seen  in  which  there  is  swelling  and  fluid.  Repeated 
examinations  of  such  cases  will  show  that  there  is  never  any 


JOINT  LESIONS  IN  CHILDREN  201 

destruction  of  the  joints.  Thej^  will  eventually  return  to 
normal.  These  must  be  looked  upon  as  the  result  of  some  very 
low  grade  infection,  or  when  a  single  joint  is  involved  it  may  be 
the  result  of  some  slight  unrecognized  trauma. 

At  the  end  of  this  second  group  period  and  also  during  the 
first  part  of  the  third  group  period  ^^■e  have  a  new  condition 


Fig.  222. — Juvenile  delorniing  osteocliondritis.  (Perthes's  disease.)  Ad- 
vanced case  shownig  marked  llattening  and  lamination  of  the  epiphy- 
sis and  thickening  of  the  neck  oF  the  femur.  There  is  no  hazing  of  the 
joint  as  is  seen  in  tuberculosis. 

which  was  first  described  by  Legg  of  Boston  and  later  in  more 
detail  by  Perthes.  The  disease  is  now  known  as  Perthes's 
disease. 

Perthes's  Disease  or  Juvenile  Deforming  Osteochon- 
dritis. In  Perthes's  original  communication  he  called  atten- 
tion to  the  fact  that  the  disease  was  limited  to  the  hip  joint. 
So  far  this  is  the  only  joint  known  to  be  in\oKed;  if  the  condi- 


202  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

tion  does  involve  other  joints  it  has  not  yet  been  recognized, 
Figs.  221  and  222. 

This  condition  is  of  peculiar  interest  in  that  it  affects  the 
hip  joint  just  at  the  age  when  tuberculous  infections  are  so 
frequent.  Its  clinical  signs  and  symptoms  are  also  closely  akin 
to  those  of  tuberculosis,  but  it  does  not  react  to  tuberculin. 
The  recovery  is  more  rapid,  and  since  there  is  but  little  destruc- 
tion, as  compared  with  tuberculosis,  the  hip  returns  more 
nearly  to  normal.  What  limitation  of  motion  remains  is  the 
result  of  mechanical  changes  in  the  joint. 

It  is  frequently  impossible  to  make  a  diagnosis  from  the 
clinical  picture,  but  in  typical  cases  the  .v-ray  appearance  is 
pathognomonic  and  when  once  seen  can  always  be  recognized. 

It  is  much  more  common  in  the  male  than  the  female,  and 
seems  to  occur  most  frequenth^  between  the  ages  of  seven  and 
twelve.  There  is  no  hazing  and  clouding  of  the  joint  as  in 
tuberculosis;  on  the  contrary  all  bone  detail  is  clean-cut  and 
sharp.  The  epiphysis  is  not  eroded  nor  worm-eaten. 

The  epiphysis  seems  to  have  softened  and  become  flattened 
out  as  if  from  pressure.  The  cartilage  is  intact,  but  the  com- 
pression of  the  epiphysis  makes  it  seem  denser  than  normal,  as 
if  there  were  increased  deposition  of  calcium  salts.  The  epiphysis 
is  occasionalh"  separated  into  several  centers  as  if  broken  by 
pressure.  The  neck  frequently  seems  broader  than  normal,  and 
there  may  be  slight  coxa  vara  present,  as  if  the  neck  had 
softened  and  was  bent.  The  lesion  apparently  confines  itself  to 
the  epiphysis  and  does  not  involve  the  acetabulum  directly 
though  changes  in  the  shape  of  the  epiphysis  of  the  head  of  the 
femur  may  later  mechanically  alter  the  acetabulum.  One  or 
both  hips  may  be  involved. 

The  etiological  factor  in  this  disease  is  unknown;  apparently 
a  condition  of  lessened  resistance  is  brought  about  with  result- 
ing secondary  changes  due  to  weight. 

Tuberculosis  and  acute  infections  continue  throughout 
the  third  group  period.  With  the  union  of  the  epiphyses  adult 
life  is  reached,  embracing  that  great  group  of  rheumatoid 
affections  which  will  be  dealt  with  in  another  chapter. 


CHAPTER  X 
JOINT  LESIONS  IN  ADULTS 


CHAPTER  X 
Joint  Lesions  in  Adults 

BEFORE  dealing  with  the  pathological  processes  in- 
voK'ing  a  joint  it  is  well  to  remember  its  parts 
A  normal  joint  consists  of  four  structures,  the  ar- 
ticulating surfaces  composed  of  cartilage,  synovial  mem- 
brane, hgaments  and  synovial  fluid.  There  is  neither  free 
bone  nor  periosteum  in  a  joint.  The  diagnosis  of  joint  condi- 
tions is  accomphshed  by  carefully  considering  the  changes  in 
one  or  more  of  these  four  parts.  The  cartilage  is  probably  the 
most  important;  it  is  the  involvement  of  this  structure  which 
leads  to  chronic  conditions.  Certain  types  of  infection  involve 
only  the  synovial  membrane,  with  secondary  changes  as  to  the 
amount  of  synovial  fluid.  In  this  type  of  joint  infection  a 
return  to  the  normal  condition  may  reasonably  be  hoped  for, 
while  when  the  cartilage  is  involved  the  return  to  a  normal 
condition  depends  largely  upon  the  severity  of  the  infection. 
The  x-ray  appearance  is  frequently  so  different  in  the  same 
condition  that  confusion  may  arise  unless  the  following  im- 
portant point  is  kept  constantly  in  mind,  namely,  that  the 
appearance  of  the  joint  changes  according  to  the  stage  of  the 
disease  obtaining  when  the  examination  is  made. 

Every  infection  may  be  divided  into  the  stages  of:  (i) 
onset,  (2)  maximum  intensity  and  (3)  repair.  It  will  be  readily 
seen  that  the  .v-ray  appearance  must  vary  in  each  of  these 
stages.  This  can  be  illustrated  graphically.  Let  the  line  A-B 
represent  a  normal  joint,  and  consider  the  curved  line  C-D  as 
representing  an  infection  where  the  cartilage  is  not  in\()l\ed. 
At  D  this  line  merges  with  the  line  A-B  and  the  joint  has 
returned  to  normal.  Now  let  the  curved  line  E-F-H  represent 
the  curve  of  some  acute  infectious  process.  It  starts  from  the 
normal  line  A-B  at  E,  and  at  F  it  reaches  its  nearest  point  to 

205 


2o6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  normal  line;  from  there,  F-H,  it  runs  parallel  to  A~B, 
This  indicates  that  permanent  changes  have  taken  place  in  the 
joint  and  that  it  will  never  return  to  normal.  The  infection  has 
disappeared,  but  there  remains  behind  a  more  or  less  perma- 
nently impaired  joint  depending  entirely  upon  the  severity  of 
the  infection.  In  the  diagram  the  numeral  i  represents  the  stage 
of  onset,  2,  the  stage  of  maximum  intensity,  and  3,  the  stage 
when  the  infection  has  subsided  and  repair  is  taking  place. 
If  an  arthritic  infection  is  considered  from  the  standpoint  of 
these  three  stages  there  will  be  no  difficulty  in  understanding 
why  the  .v-ray  changes  are  varied  in  the  same  infection. 


E  C  ^  '  D 


Fig.  223. — Graphic    illustration    of    the    stages    of   bone    infection:    (i) 
onset,  (2)  maximum  intensity  and  (3)  repair. 

Changes  Indicating  an  Arthritic  Condition.  Arthritic 
conditions  may  be  divided  into  two  classes.  First  the  acute 
polyarticular  infections  where  there  are  no  permanent  changes 
and  the  joint  returns  to  normal;  second,  that  large  group  of 
so-called   chronic   arthritides   known  as  arthritis   deformans. 

Attention  has  been  repeatedly  called  to  the  fact  that 
.v-ray  evidence  depends  upon  variations  from  the  normal,  and 
that  the  two  great  factors  producing  variations  from  normal 
are  bone  destruction  and  production.  In  a  normal  joint  there 
is  no  free  bone,  so  at  first  those  changes  must  be  considered 
which  may  be  termed  indirect  evidence,  as  the  normal  factors 
entering  into  the  structure  of  a  joint  are  not  directly  demon- 
strable upon  an  .v-ray  plate.  The  first  change  that  takes  place 
is  swelling  of  the  synovial  membrane.  In  the  majority  of  the 
joints  the  flesh  and  skin  outline  w  ill  indicate  this  by  the  enlarge- 
ment of  the  soft  tissues.  With  this  inflammatory  change  of  the 
synovial  membrane,  fluid  wifl  form;  in  most  joints  one  can 


JOINT  LESIONS  IN  ADULTS  207 

infer  this  by  the  position  of  the  part  and  the  swelling  around 
the  joint;  in  the  case  of  the  knee  the  riding  patella  will  be  seen. 
If  this  infection  is  severe  the  next  point  of  attack  will  be  the 
cartilage.  In  this  case  also  this  structure  is  not  demonstrable 
by  the  x-ray  and  again  the  condition  must  be  determined  by 
indirect  evidence,  that  is  the  width  of  the  joint  space.  If  the 
cartilage  is  uniformly  eroded,  the  bones,  because  of  the  mus- 
cular pull,  will  be  closer  together;  thus  the  joint  space  will  be 
narrowed.  The  infection  may  go  on  to  complete  destruction 
in  certain  areas  and  attack  the  bone  beneath.  The  moment 
the  bone  becomes  involved  there  is  direct  evidence  of  destruc- 
tion that  can  be  demonstrated  upon  an  .v-ray  plate. 

Cartilage  reproduces  itself  only  to  a  limited  degree,  and 
if  a  portion  is  completely  destroyed  dow'n  to  the  bone,  nature 
replaces  it  either  with  fibrous  tissue  or  with  bone.  It  is  in  this 
manner  that  what  might  be  termed  "free  bone"  in  a  joint 
is  developed. 

Besides  the  tw^o  main  factors  of  destruction  and  production 
of  bone,  atrophy  both  of  bone  and  muscle  must  also  be  taken 
into  consideration.  The  changes  just  described  do  not  take 
place  immediately,  but  extend  over  a  period  of  time.  For 
that  reason  it  is  wise  to  study  the  joints  from  the  three  stages 
already  mentioned.  In  a  previous  chapter  the  lesions  of  joints 
up  to  puberty  were  grouped  and  described  under  certain  age 
periods.  Here,  again,  it  will  be  shown  that  age  plays  an  im- 
portant part  in  rheumatic  infections.  These  will,  therefore,  be 
considered  under  the  following  groups:  (i)  those  occurring 
between  twenty  and  forty  years,  and  (2)  those  occurring  after 
the  fortieth  year. 

Acute  Polyarticular  Rheumatism.  This  disease  (Fig. 
224)  is  seen  most  frequently  between  tANcnty  and  forty  years 
of  age  and,  as  its  name  suggests,  involves  more  than  one  joint. 
In  this  lesion  the  A-ray  findings  are  rather  indefinite.  In  the 
first  stage  the  synovial  membrane  and  periarticular  tissues 
are  swollen  and  there  is  an  increased  amount  of  fluid  in  the 
joint.  In  this  stage  it  is  too  early  to  see  cartilaginous  changes, 


2o8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

and  consequently  there  is  no  necessity  to  look  for  them. 
This  first  stage  lasts  for  a  week  or  ten  days;  in  that  short 
period  of  time  no  atrophy  will  be  present.  In  the  second  stage 
of  the  disease  cartilaginous  destruction  might  be  expected. 
This,   however,  does  not  occur  in  acute  polyarticular  rheu- 


FiG.  224.  Fig.  22^. 

Fig.  224. — Acute  polyarticular  arthritis,  showing  the  ridmg  up  of  the 
patella  indicating  fluid.  There  is  no  in\oIvemcnt  of  cartilage  or  bone. 

Fig.  225. — Infectious  arthritis  in  the  hrst  stage,  showing  swelling  of  the 
soft  tissues  and  beginning  fluid  formation.  In  this  stage  it  cannot  be 
differentiated  from  acute  polyarticular  rheumatism  or  trauma  to 
the  ioint. 


matism  because  under  treatment  the  swelling  disappears.  In 
this  disease  the  second  stage  is  of  brief  duration,  consequently, 
there  is  no  atrophy.  The  third  stage,  or  the  stage  of  repair, 
is  reached  in  about  three  weeks  after  which  the  joint  is  again 
normal. 

The  only  changes,  then,  seen  throughout  the  disease  are 


JOINT  LESIONS  IN  ADULTS  209 

swelling  and  fluid  in  the  joint.  No  atrophy  is  present,  as  the 
duration  of  the  disease  is  too  short.  These  changes  are  not 
pathognomonic,  as  exactly  the  same  x-ray  changes  are 
seen  in  a  traumatic  injury  to  a  joint,  or  in  the  first  stage  of  an 
infectious  arthritis,  which  will  be  described  later. 

Chronic  Arthritis.  In  considering  the  chronic  rheu- 
matic infections  great  difficulties  are  encountered.  The 
classifications  of  the  various  types  under  this  head  are  very 
unsatisfactory,  and  then  too  these  chronic  rheumatisms 
have  many  names  for  the  same  condition.  For  example,  the 
terms  chronic  rheumatism,  arthritis  deformans,  rheumatoid 
arthritis,  osteoarthritis,  spondylitis,  etc.,  are  used  indiscrimi- 
nately by  different  individuals  to  mean  the  same  condition. 
There  is  no  classification  which  is  absolutely  satisfactory, 
but  that  adopted  by  Goldthwaite  many  years  ago  is,  taken 
as  a  whole,  probably  the  best.  Of  course  many  take  exception 
to  this  classification  and  do  not  agree  with  it  in  its  entirety; 
but  its  simplicity  and  the  great  number  of  cases  which  can  be 
classified  according  to  it  make  it  seem  to  be  generall\'  the 
most  useful. 

He  divides  chronic  arthritis  into: 

1.  The  infectious  type.  This  includes  tuberculosis,  gonor- 
rhea, lues,  pneumococcic  infections,  etc.,  and  those  types  of 
arthritis  which  have  the  same  clinical  manifestations,  l3ut 
where  the  exact  etiological  factor  is  unknown. 

2.  Those  cases  designated  as  atrophic  arthritis.  It  is 
questionable  whether  this  group  can  be  looked  upon  as  a 
distinct  entity. 

3.  Hypertrophic  arthritis. 

Injections  Arthritis.  This  group  does  not  seem  to  be 
limited  to  any  age  period,  and  is  just  as  prevalent  in  the  second 
as  in  the  third  age  period.  It  is  true  that  certain  acute  infections, 
such  as  gonorrhea  or  tuberculosis,  arc  much  more  common 
in  the  second  age  period. 

From  an  x-ray  standpoint,  infectious  arthritis  presents 
three   different    appearances   according   to   the  stage   of  the 


210  INJURIES  AND  DISEASES  OE  BONES  AND  JOINTS 

disease  at  the  time  of  the  examination.  In  the  first  stage, 
(Fig.  225),  at  the  onset  of  the  infection,  the  plate  shows  distinct 
swelling  of  the  soft  tissues  around  the  joint  with  increase  of  the 
synovial  fluid.  There  is  no  cartilaginous  destruction,  evi- 
denced by  the  fact  that  the  joint  spaces  are  of  normal  width. 
Since  the  cartilage  has  not  been  involved,  of  necessity  there  can 
be  no  bone  change.  There  is  no  atrophy,  as  sufficient  time  has 
not  elapsed  to  bring  about  this  condition. 


Fig.  226. — Second  stage  of  infectious  arthritis,  showing  destruction  with 
narrowing  of  joint  space,  but  no  new  bone  production. 

This  stage  gives  the  same  .v-ray  appearance  as  an  acute 
polyarticular  rheumatism  or  an  injury  to  the  joint  without 
fracture,  because  in  these  conditions  fluid  and  periarticular 
swelling  are  also  present,  and  no  cartilaginous  changes  appear. 

In  the  second  stage  the  disease  probably  reaches  its  maxi- 
mum intensity,  and  in  time  the  following  changes  take  place 
in  the  joint  and  bone.  Sufficient  time  has  elapsed  for  the  joint  to 
become  more  or  less  immobilized  either  from  pain  or  treatment, 
consequently  atrophy  of  the  bones  forming  the  joint  appears. 

J 


JOINT  LESIONS  IN  ADULTS  211 

The  swelling  and  fluid  are  still  present.  The  cartilage  in  this 
stage  has  become  involved  and  may  be  more  or  less  destroyed 
according  to  the  severity  of  the  infection;  this  is  evidenced  by 
the  fact  that  the  joint  space  is  narrowed,  Fig.  226.  The  infec- 
tion may  have  localized  sufficiently  at  one  part  of  the  joint  to 
destroy  all  the  cartilage  and  actually  involve  the  bone  beneath; 
in  this  case  any  bone  change  can  be  easily  seen  upon  the  plate. 
While  the  soft  tissues  around  the  joint  are  still  swollen  there 
may  be  atrophy  of  the  soft  tissues  above  and  below  the  joint. 
This  is  particularly  true  in  long-standing  infections,  such  as 
tuberculosis.  This  second  stage  is  variable  as  to  length  of  time, 
and  the  same  changes  persist  as  long  as  the  infection  is  active. 
The  atrophy,  however,  becomes  greater  the  longer  this  acute 
stage  exists.  There  is  no  production  of  new  bone,  as  this  is  a 
repair  process  and  cannot  take  place  during  the  height  of  the 
disease. 

With  the  subsiding  of  the  infection  the  third  stage,  or  stage 
of  repair,  is  ushered  in.  Here,  too,  the  picture  is  slightly  differ- 
ent depending  upon  whether  the  examination  is  made  at  the 
beginning  or  at  the  end  of  this  stage.  The  swelling  and  fluid 
have  disappeared,  the  atrophy  is  still  present,  and  will  only 
disappear  when  the  joint  begins  to  function  again.  The  de- 
structive process,  however,  has  ceased  and  repair  now  takes 
place.  Unfortunately  the  cartilaginous  surfaces  which  are  so 
easily  attacked  have  but  little  recuperative  powers  in  them- 
selves. Cartilage  only  reproduces  itself  to  a  limited  extent,  and, 
in  areas  where  it  is  completely  destroyed,  it  does  not  fill  in;  so 
nature  has  to  fall  back  upon  two  substitutes:  the  destroyed 
area  is  either  filled  in  with  fibrous  tissue,  or  the  raw,  exposed 
bone  proliferates,  filling  up  the  destroyed  area.  This  over- 
growth is  spoken  of  as  an  exostosis.  Fig.  227. 

The  extent  of  the  overgrowth  of  bone  is  dependent  entirely 
upon  the  extent  and  severity  of  the  infection.  Where  two 
opposing  articulating  surfaces  are  denuded  of  cartilage,  the 
resulting  new  bone  formation  from  both  surfaces  may  unite 
and  produce  an  actual  bony  ank^dosis.   It  is  interesting  to 


212  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

note  that  the  infection  or  its  toxin  shows  a  marked  predilec- 
tion for  the  ligamentous  attachments,  and  the  first  bone 
proliferation  is  found  at  these  points. 

W  hen  the  joint  has  recovered  as  far  as  it  is  possible  there 
is  absence  of  swelling  and  fluid,  atrophy  has  disappeared,  and 


Fig.  227. — Third  stage  of  infectious  arthritis.  The  infection  has  now  sub- 
sided and  repair  is  taking  place.  The  damaged  cartilage  is  replaced  by 
new  production  of  bone  and  the  joint  is  permanently  damaged  ac- 
cording to  the  severity  of  the  infection. 

there  is  the  marked  formation  of  exostoses  or  actual  bony 
ankylosis  depending  entirely  upon  the  severity  of  the  lesion. 

While  this  is,  relatively  speaking,  a  rough  picture  of  what 
happens  in  infectious  arthritis  there  are  variations  depending 
upon  the  particular  type  of  infection. 

The  foregoing  analysis  applies  to  the  subdivisions  under 
infectious  arthritis  of  known  etiology.  The  question  naturally 


JOINT  LESIONS  IN  ADULTS  213 

arises,  do  any  of  these  conditions  give  such  definite  .v-ray 
changes  that  the  roentgenologist  can  actually  determine  the 
specific  type  of  infection  with  which  he  is  dealing.  Unfortu- 
nately the  majority  of  them  give  the  same  .\-ray  indications. 
Some,  however,  such  as  tuberculosis,  gonorrhea  and  lues, 
give  fairly  constant  appearances,  so  that  they  can  often  be 
recognized. 

Tuberculosis.  (Figs.  228  and  229.)  In  this  lesion  there  is  at 
first  the  swelling  and  fluid  which  is  characteristic  of  most  joint 
lesions.  Soon,  however,  the  joint  becomes  hazy  and  indistinct. 
In  fact,  it  suggests  a  very  poor  plate,  but  in  this  same  plate  it 
will  be  noted  that  the  bones  adjacent  to  the  affected  joint 
come  out  sharply  and  distinctly.  Only  the  joint  itself  is  hazy  and 
indistinct.  This  is  probably  due  entirely  to  the  changes  in  the 
synovial  membrane.  The  joint  spaces  have  become  narrowed, 
owing  to  the  destruction  of  the  cartilaginous  surfaces,  and 
upon  close  inspection  of  the  plates  it  will  be  found  that  the 
bone  contour,  that  is,  the  bone  beneath  the  cartilage,  is  very 
indistinct,  irregular  and  worm-eaten.  Fluid  and  periarticu- 
lar swelling  are  still  present,  and  if  the  lesion  is  of  some 
duration  the  plate  shows  the  spindle-shape  joint  of  tuberculosis 
due  to  atrophy  of  the  soft  tissues  above  and  below  the  swollen 
joint.  There  is  also  marked  atrophy  of  the  bones,  due  to 
deposition  of  fat  in  the  bone. 

When  the  stage  of  repair  takes  place  the  haziness  and 
indistinctness  disappear,  but  there  remain  behind  the  ir- 
regular worm-eaten  ends  of  the  bones  more  or  less  completely 
denuded  of  cartilage.  Theoretically  the  repair  process  should 
take  place  with  replacement  of  cartilage,  but  unfortunately 
this  structure  has  but  little  recuperative  power.  Bone  and 
fibrous  tissue  are  the  only  other  substances  that  nature  has 
at  her  disposal  in  this  region,  and  consequently  the  denuded 
areas  in  this  type  of  disease  are  replaced  entirely  by  fibrous 
tissue.  For  some  reason  but  little  bone  production  is  en- 
countered in  tuberculous  joints.  \\  hen  ankylosis  takes  place 
it  is  almost  entirely  fibrous  in  character.  Since  the  disease  is  of 


2  14  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

long  duration  and  the  joint  more  or  less  fixed,  the  muscular 
pull  phis  the  lesion  in  the  joint  produce  marked  subhixations. 
Since  these  joints  are  so  frequently  untreated,  the  formation 
of  sinuses  is  quite  common,  and,  just  as  in  children's  joints, 
a  secondary  infection  ensues.  In  these  mixed  infections  marked 
new  bone  formation  is  seen.  Tuberculosis  of  the  joints  is  largely 
a  disease  of  childhood  and  of  the  first  twenty  years  of  adult 


Fig.  228. — Tuberculous    arthritis   of  the   wrist,  showing  swelhng,  hazing 
and  destruction  of  cartilage  and  bone. 

life,  though  occasionally  one  sees  an  acute  tuberculous  joint 
after  forty  years  of  age.  Practically  any  joint  can  be  inyolved; 
tuberculosis  of  the  shoulder  joint,  howeyer,  is  uncommon  in 
childhood  and  early  adult  life. 

Caries  Sicca.  After  fort}-  years  of  age  one  form  of 
tuberculosis  deyelops  whose  fayorite  site,  curiously  enough, 
is  the  shoulder  joint.  Fig.  230.  Caries  sicca  presents  a  totally 
diflerent  .v-ray  picture.  There  is  neyer  any  lluid,  swelling  or 
hazing.  The  cartilage  is  destroyed,  the  bone  beneath  is  worm- 


JOINT  LESIONS  IN  ADULTS  215 

eaten,  and  frequently  gouged-out  areas  are  present  just 
beneath  the  joint  surfaces.  These  changes  are  sharp  and  clean- 
cut  in  outline.  The  striking  features  are  the  extreme  atrophy 
of  the  bones  and  soft  tissues.  The  soft  tissues  have  become  so 
atrophied  that  the  curve  of  the  shoulder  disappears  com- 
pletely, clinically  simulating  a  subluxation.  The  synovial 
membrane  has  also   contracted;   consequently,   the   head   of 


Fig.  229. — Tuberculous  arthritis  of  the  knee,  almost  healed.  Notwith- 
standing the  extensive  destruction,  the  joint  is  clear  cut  as  the  hazy 
indistinct  joint  is  only  present  during  the  active  process  of  the  dis- 
ease. 

the  bone  is  pulled  high  up  in  the  glenoid  fossa.  It  is  frequently 
difficult  to  get  a  good  plate  on  account  of  the  extensive  i^one 
atrophy. 

Gonorrheal  Arthritis.  Gonorrheal  arthritis  (Fig.  231) 
does  not  present  a  distinct  .v-ray  appearance.  The  roentgeno- 
gram varies  according  to  the  severity  of  the  lesion.  Only  in 
the  knee-joint  are  there  fairly  definite  characteristics.   For 


2i6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

some  reason  in  that  particular  joint  the  greatest  severity  of 
the  lesion  manifests  itself  just  beneath  the  patella,  and  early 
bone  ankylosis  occurs.  This  condition  may  result  from  other 
infections,  but  according  to  our  present  knowledge  ankylosis 
between  the  patella  and  femur  is  nearly  always  looked  upon 


Fig.  230. — Caries  sicca  of  the  shoulder  joint.  Note  the  marked  atrophy 
of  the  bone  and  soft  tissue  with  marked  bone  destruction.  This  is 
a  lesion  of  the  third  age  period  and  since  there  is  no  swelhng  of  the 
soft  tissue  and  fluid,  we  do  not  have  the  characteristic  hazing  of  the 
joint  seen  in  the  other  form  of  joint  tuberculosis. 

as  of  gonorrheal  origin  unless  the  idcntit}^  of  some  other 
organism  can  be  definitely  established.  The  usual  changes 
in  a  gonorrheal  joint  are  those  of  acute  destruction  with 
new  bone  production  and  frequent  ankylosis.  This  lesion  is 
by  far  the  most  frequent  in  early  adult  life. 


JOINT  LESIONS  IN  ADULTS 


217 


Luetic  Arthritis.  Luetic  arthritis  (Fig.  232)  shows  marked 
periarticular  swelling,  thickening  of  the  synovial  membrane 
and  fluid  in  the  joint.  This  type  does  not  go  on  to  cartilagin- 
ous destruction,  consequently  when  the  disease  subsides  it 
leaves  a  perfectly  normal  joint.  The  x-ray  appearance,  as  far  as 


• 


Fig.  231. — Gonorrheal  arthritis  with  beginning  changes  of  the  under  sur- 
face of  the  patella,  and  the  tibia  and  femur.  The  changes  are  similar 
to  other  types  of  infections  of  the  joint,  except  that  in  gonorrheal 
arthritis  there  is  patella  involvement,  although  this  may  not  always 
be  present. 

the  joint  is  concerned,  is  identical  witli  that  of  an  acute 
polyarticular  rheumatic  or  a  traumatic  joint.  Fortunately  in 
the  majority  of  cases  this  type  of  arthritis  is  generally  accom- 
panied by  bone  change,  and  while  this  change  is  not  in  the 
joint  itself,  it  is  fairly  characteristic,  and  may  be  recognized 


2i8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

as  a  small  area  of  periostitis  formed  just  at  the  chondro- 
periosteal  junction.  This  periostitis,  in  conjunction  ^vith  peri- 
articular swelling  and  fluid  in  the  joint,  is  fairly  characteristic 
of  a  luetic  lesion.  This  lesion  is  seen  most  frequently  in  early 
adult  life.  The  question  will  immediately  be  raised  that  peri- 


FiG.  232. — Luetic   arthritis   with   periosteal   changes   close   to   the   joint. 

ostitis  occurs  with  other  forms  of  acute  joints.  This  is  perfectly 
true  but  the  differential  point  is  that  in  such  joints  there  is 
always  destruction  in  the  joint  itself  while  in  syphilis  the 
periostitis  is  associated  with  no  joint  destruction. 

The  remaining  forms  of  infectious  arthritis  do  not  give 
any  definite  A-ray  appearances  but  varj'  according  to  the  type 
and  virulence  of  the  infection. 


JOINT  LESIONS  IN  ADULTS 


219 


Atrophic  Arthritis.  This  lesion  (Fig.  233)  is  generally 
seen  in  early  and  middle  age,  between  the  ages  of  twenty  and 
forty.  There  is  marked  atrophy  of  both  the  soft  tissues  and  bone. 
The  joints  are  frequently  partially  subluxated  due  to  muscu- 
lar contraction  and  there  is  partial  ankylosis  not  due  to  bone 


Fig.  233. — Atrophic  arthritis.  Note  the  marked  atrophy  of  the  bone  and 

soft  tissues. 


but  to  fibrous  changes  and  muscle  contracture.  The  .v-ray 
examination  shows  marked  atrophy  of  bone  and  soft  tissue. 
There  is  extensive  absorption  of  cartilage  and  its  complete 
destruction  in  certain  areas,  but  apparently  nature  makes  no 
attempt  at  new  bone  formation.  From  this  brief  description 
one  can   readily   see   that   atrophic   arthritis  simulates  very 


220  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

closel}'  the  second  stage  of  infectious  arthritis.  The  differential 
point  is  that  at  no  stage  in  this  disease  is  there  any  fluid  or 
periarticufar  sweffing,  whife  in  the  second  stage  of  infectious 
arthritis  there  is  both  sweffing  and  ffuid.  Many  cfinicians 
thinic  that  atrophic  arthritis  is  not  a  distinct  cfinicaf  entity, 
but  probabfy  an  atypicaf  manifestation  of  infectious  arthritis. 


Fig.  234. — Hypertrophic     arthritis     showing    uvergro\\'th    of    bone,    ex- 
ostoses and  joint  mice  lying  beneath  the  head  of  the  femur. 

Hypertrophic  Arthritis.  Hypertrophic  arthritis  (Fig.  234) 
is  a  disease  afmost  invariabfy  associated  with  peopfe  of  middfe 
and  ofd  age.  One  rarefy  sees  this  type  in  those  under  forty,  and 
it  is  most  pronounced  in  patients  in  the  neighborhood  of  fifty 
and  over,  so  it  may  be  said  that  this  is  a  disease  of  the  third 
age  period.    ,<, 


JOINT  LESIONS  IN  ADULTS 


221 


Attention  has  already  been  drawn  to  the  fact  that  as  we 
grow  older  there  is  a  generalized  atrophy  of  all  the  bones 
which  we  look  upon  as  a  normal  change  due  to  old  age.  Conse- 
quently, since  this  disease  is  one  of  old  age,  one  would  naturally 
expect  to  find  this  atrophic  change  in  hypertrophic  arthritis; 
on  the  contrary,   however,  the  .v-ray  examination  shows  no 


Fig.  235. — Note  the  calcified  bodies  (joint  mice)  1\  ing  in  the  quadriceps  of 
the  bursa.  These  are  frequently  seen  in  hypertrophic  arthritis  and 
cause  the  mechanical  locking  of  the  joint. 


atrophy  and  apparently  an  increased  deposition  of  calcium 
salts,  so  that  the  bone  shadows  are  even  a  little  denser  than 
normal. 

There  is  no  swelling  or  fluid  in  the  joint.  The  cartilage  is 
destroyed  in  focal  spots  and  in   these  areas  bony  exostoses 


222  INJURIES  AND  DISEASES  OE  BONES  AND  JOINTS 

appear  and  there  is  marked  new  bone  formation  at  the  attach- 
ments of  the  ligaments  of  the  joint.  Frequently  little 
bony  bodies  may  be  present  lying  free  in  the  joint  cavity, 
Fig.  235.  In  this  condition  these  joint  mice  may  become 
engaged  in  the  joint,  resulting  in  swelling  and  fluid;  but  this  is 
an  accidental  factor,  and  is  not  the  normal  course  of  the  disease. 
There  may  be  ankylosis  of  the  joint,  but  this  is  not  a  true 
ankylosis  due  to  fibrous  tissue  or  bone  union,  simph'  a  mechan- 
ical locking  of  opposite  engaging  exostoses.  This  type  simulates 
the  third  stage  or  the  stage  of  repair  in  an  infectious  arthritis. 
The  two  conditions,  however,  would  only  be  confused  in  old 
people  since  the  hypertrophic  type  does  not  exist  in  the  second 
age  period.  In  hypertrophic  arthritis  there  is  increased  density 
of  bone,  while  in  infectious  arthritis  there  would  be  the  normal 
atrophy  of  age. 

Briefly  to  summarize  the  difl^erence  between  these  different 
conditions   the   following   points   are   to   be   borne  in  mind: 

Acute  polyarticular  rheumatism  and  the  first  stage  of 
infectious  arthritis  may  occur  at  the  same  age  and  are  not 
distinguishable  until  the  stage  of  destruction  appears  in 
infectious  arthritis.  The  beginning  of  the  third  stage  of  infec- 
tious arthritis  and  the  atrophic  type  both  show  destruction 
and  no  bone  production  and  occur  at  the  same  age,  but  there 
is  atrophy  of  both  bone  and  soft  tissue  in  the  latter  type, 
while  there  still  remains  some  soft  tissue  swelling  in  the  former 
type. 

The  infectious  arthritis  of  old  age  can  be  distinguished  from 
the  hypertrophic  type  by  the  fact  that  with  the  former  there 
is  the  bone  atrophy  of  old  age  while  with  the  latter  there  is 
increased  density  of  bone. 

Atrophic  arthritis  is  seen  largely  in  the  second  age  period, 
hypertrophic  arthritis  in  the  third  age  period,  ^^■hiIe  infectious 
arthritis  occurs  in  anj-  age  period. 

Arthritic  Changes  due  to  Age.  Great  care  must  be 
taken  not  to  confuse  the  slight  arthritic  changes  which  are 
always  present  in  old  people  with  an  acute  active  process.  It 


JOINT  LESIONS  IN  ADULTS  223 

has  been  definitely  established  that  practically  all  of  us  when 
we  reach  the  age  of  forty-five  show  small  exostoses  in  and 
around  the  joints,  particularly  where  the  ligaments  attach,  and 
yet  there  may  be  no  clinical  manifestations  of  an  arthritic 
process.  This  naturally  means  that  there  is  a  quiescent  arthritis 
present,  which  only  needs  the  proper  stimulation  to  become  an 
active  process.  It  is  in  just  these  cases  that  such  marked  symp- 
toms follow  a  slight  injury — symptoms  out  of  proportion  to  the 
extent  of  the  injur}-.  In  this  condition  it  must  be  remembered 
that  the  injury  has  simply  lowered  the  resistance  of  the  joint 
and  has  allowed  this  quiescent  arthritis  to  Hare  up  into  an 
active  process,  so  that  the  marked  clinical  manifestations  seen 
in  such  joints  are  reall}'  the  result  of  the  arthritis  and  not  of  the 
trauma. 

The  writers  have  frequently  seen  cases  where  the  ankle  and 
entire  foot  have  been  enormously  swollen  following  a  slight 
injury,  the  swelling  and  tenderness  being  so  marked  as  to 
suggest  fracture  of  several  bones;  but  the  x-ray  examination 
showed  a  low  grade  infectious  arthritis  indicated  by  small 
exostoses,  and  one  or  two  of  these  might  actually  have  been 
broken  off.  These  cases  always  do  better  when  treated  from  an 
arthritic  standpoint  rather  than  as  an  injury. 

Arthritis  in  the  Spine.  These  arthritic  lesions  produce 
the  same  changes  in  the  spine  as  in  other  joints.  There  are, 
however,  two  special  types  of  arthritis  occurring  in  the  spine, 
the  acute  spondylitis  deformans,  and  the  Alarie-Strumpell 
type  of  spondylitis.  Since  all  lesions  of  the  spine  will  be  taken 
up  in  a  separate  chapter  in  order  that  the  differential  points 
may  be  more  clearh^  brought  out,  these  two  lesions  will  be 
discussed  there. 

Villous  Arthritis.  In  closing  this  discussion  upon 
arthritis  it  seems  ad\isable  to  mention  briclly  the  so-called 
villous  arthritis.  Fig.  236.  An  .v-ray  plate  of  such  a  joint  will 
show  a  swollen  and  thickened  synovial  membrane  so  thick 
that  at  times  the  folds  of  the  membrane  can  be  demonstrated. 
The  bony  and  cartilaginous  changes  are  very  variable,  ranging 


224  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

from  a  normal  joint  to  the  hazing  and  clouding  of  a  tuber- 
culous joint.  It  seems  to  the  writers  that  this  term  "villous" 
is  a  most  unfortunate  one,  as  it  describes  a  symptom  rather 
than  a  conchtion.  This  \'iIIous  change  has  been  observed  in  an 
old,  chronically  inllamed  traumatic  joint,  in  tuberculosis,  in 
infectious   and    in    hypertrophic   arthritis.    It    is   a   condition 


Fig.  236. — The  marked  synovial  thickenino;  m  villous  arthritis. 

brought  about  apparently  by  any  long-continued  irritation  of 
the  synovial  membranes,  consequently  the  term  should  not  be 
used  to  designate  a  certain  type  of  arthritis. 

Non-arthritic  Joint  Lesions.  Besides  these  arthritic 
conditions  which  we  have  attempted  to  describe,  there  are 
four  lesions  \Nhich  involve  joints  and  yet  cannot  be  properly 


JOINT  LESIONS  IN  ADULTS  225 

looked  upon  as  arthritic  in  character,  namcl\',  gout,  Charcot 
joint,  syringomyelia  and  the  joints  of  hemophilia. 

Gout.  Gout  is  a  disease  of  the  third  age  period;  it  occurs 
more  frequently  in  the  male  than  in  the  female  and  is  relatively 
infrequent  when  compared  to  other  joint  lesions.  In  charac- 
teristic cases  where  there  are  large  deposits  of  urates  the  x-ray 
appearances  are  quite  typical.  There  is  periarticular  swelling, 
and  on  account  of  pain  there  is  immobilization  of  the  joint, 
producing  some  atrophy.  The  characteristic  changes  are 
punched-out  areas  in  the  bones  at  the  margins  of  the  articular 
surfaces.  Fig.  237.  These  punched-out  areas  vary  in  size, 
sometimes  being  so  large  as  to  involve  the  entire  joint  surface. 
They  are  generally  filled  with  urates,  and  since  urates  do  not 
cast  shadows  we  get  these  apparent  holes  in  the  articulating 
surfaces. 

In  the  very  early  stages  of  the  disease  there  is  some  new 
bone  formation  in  the  shape  of  exostoses  such  as  are  seen  in 
arthritis.  In  fact,  at  this  stage  of  the  disease  the  x-ray  appear- 
ance is  very  similar  to  that  of  hypertrophic  arthritis,  Fig.  238. 

In  the  advanced  stage  of  the  disease,  particularly  if  a  knee  is 
involved,  the  destruction  may  be  so  great  as  to  simulate  a 
Charcot  joint.  The  phalangeal  joints  of  the  hands  and  feet  are 
most  commonly  involved,  and  give  the  most  typical  picture. 
When  the  long  bone  joints  are  involved  the  changes  are  most 
apt  to  be  of  the  hypertrophic  arthritic  type. 

Charcot  Joint.  The  acute  luetic  joint  which  is  looked  upon 
as  infectious  in  origin  has  already  been  described.  Wliile  the 
Charcot  joint  is  luetic  in  origin  it  does  not  take  place  in  the  acute 
infectious  stage  of  the  disease,  but  is  secondary  to  changes 
taking  place  in  the  nervous  s^^stem  in  the  tertiary  stage 
of  the  disease.  It  may  be  spoken  of  as  neuropathic  in  origin. 
Since  it  is  associated  with  the  late  manifestations  of  lues, 
it  should  not  be  k)oked  for  in  the  young;  it  is  entirelv  a  disease 
of  middle  or  old  age,  that  is  of  the  third  age  period. 

Any  joint  may  be  affected,  but  the  knee,  hip,  ankle  and 
spine  are  most  commonly  involved.   Since  these  joints  are 


226  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  237. — Showing  the  punched-out  areas  of  the  articulating  surfaces  of 
the  joints  so  characteristic  of  gout. 


JOINT  LESIONS  IN  ADULTS 


22' 


/ 


Fig.  238. — Early  case  of  gout  where  the  typical  punched-out  areas  liave  not 
appeared.  There  is  definite  new  bone  formation  in  the  shape  of 
exostoses,  simulating  the  clianges  seen  in  hypertrophic  artliritis. 


228  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  239.- — Charcot   joint   showing  the  complete  destruction  of  the  joint 
with  bony  detritus  in  the  bursa.  Note  that  there  is  no  atrophy  present. 


JOINT  LESIONS  IN  ADULTS 


229 


Fig.  240. — Anteroposterior  \'icw  of  the  same  joint. 


230  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

weight-bearing  thej^  show  the  most  typical  changes.  The  knee 
is  involved  more  frequently  than  any  other  joint  and  an 
x-rsiy  examination  of  this  joint  gives  the  best  picture,  Figs. 
239  and  240.  The  most  striking  change  noted  is  the  very 
extensive  destruction  of  the  joint.  The  condyles  of  the  femur 


Fig.  241. — Charcot  joint  of  the  ankle  showing  the  marked  periostitis  of 
the  tibia  and  fibula  associated  with  extensive  joint  changes. 

are  broken  off,  more  or  less  disintegrated  and  pushed  aside, 
so  that  the  lower  end  of  the  femur  rests  upon  the  tibial  articu- 
lation and  by  pressure  actually  gouges  it  out.  The  bones  become 
softened  and  the  calcium  salts  are  compressed  so  that  the  bone 
in  this  area  is  dense  and  much  eburnated.  The  joint  is  very 
much  swollen  and  there  is  fluid  present. 

The  periosteum  above  the  joint  is  affected  so  that  there  is 


JOINT  LESIONS  IN  ADULTS 


231 


a  marked  periosteal  reaction,  Fig.  241.  As  one  views  such  a 
joint  with  the  marked  destruction,  one  is  forced  to  conclude 
that  this  extensive  destruction  must  have  taken  place  over  a 
long  period  of  time  and  also  that  on  account  of  the  great 
disintegration  such  a  joint  shoukl  be  extremely  pamfuk 


Fig.  242. — Hemorrhagic  cysts  beneath  the  cartilage  oi  the  joint  seen  in 

hemophiha. 

If  these  deductions  were  correct,  namely,  that  the  joint 
was  ver}^  painful  and  that  the  condition  had  existed  over  a 
long  period  of  time,  then  there  would  be  disuse  of  that  joint 
resulting  in  extreme  atrophy  of  the  bones.  On  the  contrary 
the  plate  shows  that  the  bones  are  really  denser  than  normal, 
just  the  reverse  of  atrophy.  The  absence  of  atrophy  then 
forces  the  conclusion  that  the  joint  has  been  in  constant  use, 


232  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


and  since  this  would  not  ])e  the  case  if  it  were  painful  the 
conclusion  is  inevitable  that  the  joint  was  painless  upon 
motion.  No\n'  there  are  only  two  conditions  in  which  disin- 
tegration of  joints  exists  without  great  pain,  and  the  most 
common  of  these  is  the  Charcot  joint. 


Fig.  243.  Fig.  244. 

Fig.  243. — Hemophiliac    joint    with    the    joint    surfaces    and   the    bone 

beyond  the  joint  destroyed  by  hemorrhage. 
F'iG.  244. — Organization  of  hemorrhage  in  the  elbow  joint  in  hemophiha. 

Syringomyelia.  It  must  be  borne  in  mind  that  the  lesions 
of  this  disease  are  neuropathic  in  origin  and  give  practically 
the  same  x-ray  changes  as  Charcot  joint,  except  that  the 
lesions  are  largely  confined  to  the  upper  extremities,  while  in 
Charcot  joint  the  weight-bearing  joints  are  the  ones  most 
commonly  involved.  Every  case  in  which  absence  of  atrophy 
is  seen  in  connection  with  a  I^adly  disorganized  joint  shoufd  be 


JOINT  LESIONS  IN  ADULTS  233 

viewed  either  as  Charcot  or  syringomyelia  according  to  whether 
the  lesion  involves  the  upper  or  lower  extremity.  In  certain 
cases  it  may  be  impossible  to  differentiate  them  without  the 
clinical  history. 

Hemophilia.  Occasionally  one  sees  a  joint  giving  the 
clinical  symptoms  of  an  infectious  arthritis,  yet  the  .\-ray  ex- 
amination shows  a  rather  remarkable  joint  condition.  There 
are  areas  of  marked  destruction  of  the  cartilage  with  gouged- 
out  areas  extending  through  the  cartilage  into  the  bone, 
Fig.  242.  Sometimes  there  will  be  circular  gougcd-out  areas 
in  the  bone  behind  the  cartilage  but  not  involving  it.  Fig.  243. 
Again  there  may  be  complete  destruction  of  the  entire  surface 
of  the  joint,  and  a  suffusion  of  blood  into  the  synovial  cavit>' 
which  may  go  on  to  actual  organization  and  deposition  of  cal- 
cium salts.  Fig.  244. 

The  joint  is  hazy  and  indistinct  and  may  simulate  tuber- 
culosis, but  the  differential  points  to  be  noted  are  the  gouged- 
out  areas  behind  the  joint  surfaces  or  the  organized  blood 
clots  which  do  not  occur  in  tuberculosis.  When  such  a  con- 
dition is  present  it  is  invariably  the  result  of  hemophilia. 

Arthritic  Changes  in  Ligaments.  Besides  these  joint 
conditions  certain  changes  take  place  in  the  ligaments  and 
bursae,  \\  hich,  while  not  involving  joints,  should  be  looked 
upon  as  arthritic  in  origin.  In  the  chronic  arthritic  group 
there  is  alw  ays  more  or  less  calcification  of  the  ligaments  at 
their  bony  attachments,  suggesting  that  these  deposits  are 
exostoses;  but  the  deposits  are  entirely  in  the  ligaments, 
Fig.  245.  This  is  particularly  true  in  the  tendo  Achillis  and 
the  quadriceps,  attachment  to  the  patella.  The  entire  crests 
of  the  ilia  may  be  roughened  from  the  same  condition.  These 
changes  may  frequently  precede  the  joint  changes  and  should 
always  be  looked  upon  as  infectious  in  origin.  There  are  two 
bursae  which  seem  to  be  the  favorite  site  for  arthritic  changes, 
(i)  the  subdeltoid,  and  (2)  the  bursa  situated  at  the  attach- 
ment of  the  plantar  fascia  to  the  os  calcis.  The  latter  condition 
is  known  as  exostoses  of  the  os  calcis  or  painful  heels. 


234  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Subdeltoid  Bursitis.  The  subdeltoid  bursa  is  situated 
just  at  the  external  side  of  the  greater  tuberosity  of  the  hu- 
merous  and  about  five  mm.  from  the  cortex.  Calcium  deposits 


Fig.  245. — Trauma  following  upon  an  arthritic  condition,  producing 
marked  new  bone  formation  in  the  tendo  Achilhs.  Of  course,  this  is 
an  exaggerated  case. 

take  place  in  the  walls  of  the  bursa  and  not  in  the  bursa 
itself.  This  usually  brings  about  a  very  painful  condition 
with  limitation  of  motion.  The  x-rav  examination  will  show 


JOINT  LESIONS  IN  ADULTS 


235 


Fig.  246. — Showing  deposition  of  salts  in  the  subdeltoid  bursa. 


Fig.  247. — Deposition    of    caleiuni    salts    in    the    subdeltoid    bursa. 


236  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  248. — The  non-gonorrheal  type  of  exostosis  of  the  os  calcls.   It  has 
the  same  structure  as  the  bone  itself. 


Fig.  249. — Gonorrheal  exostosis.  The  calcification  takes  place  at  the 
attachment  of  the-planta  fascia  where  there  is  a  small  bursa  and  finally 
unites  with  the  os  calcis. 


JOINT  LESIONS  IN  ADULTS  23- 

a  deposit  of  calcium  salts  just  to  the  outer  side  of  the  greater 
tuberosity  JDut  not  attached  to  it.  With  no  history  of  injury 
the  diagnosis  is  easy  to  make,  Figs.  246  and  247.  In  a  certain 
number  of  cases,  however,  this  deposition  may  take  place 
without  the  production  of  any  symptoms  at  all.  In  such 
conditions  a  trauma  of  the  shoulder  will  produce  an  acutely 
painful  joint  with  limitation  of  motion.  The  .v-ray  will  show 
these  calcium  deposits;  but  with  apparently  a  normal  joint 
before  injury  and  symptoms  following  the  trauma,  it  is  fre- 
quently impossible  to  determine  whether  this  is  a  subdeltoid 
bursitis  or  a  small  fragment  of  bone  torn  off  by  the  attach- 
ments of  the  suprascapular  muscles.  The  diagnosis  some- 
times can  only  be  made  by  observing  the  course  of  the  disease; 
if  the  symptoms  do  not  subside  with  fixation  of  the  arm  the 
condition  is  probably  a  bursitis  and  not  a  hgamentous  tearing. 
This  condition  is  not  seen  in  the  young,  but  is  most  common 
in  the  third  age  period. 

Exostosis  of  the  Os  Calcis.  Two  types  of  deposit  arc  noted 
in  exostosis  of  the  os  calcis,  both  infectious  in  origin.  The 
condition  is  generally  known  as  painful  heels.  In  one  type 
there  is  an  exostosis  springing  from  the  os  calcis  at  the  point 
of  the  plantar  fascia  attachment,  Fig.  248.  It  starts  from  the 
bone,  grows  outward  like  a  stalactite,  has  the  same  structure 
as  the  bone  and  is  a  true  exostosis.  It  is  most  frequent  in  the 
latter  part  of  the  second  and  all  of  the  third  age  period. 

The  second  type  is  of  gonorrheal  origin  (Fig.  249),  and  the 
calcium  salts  are  deposited  first  in  the  bursa  at  a  short  dis- 
tance from  the  cortex.  Then  fresh  deposits  arc  subsequently 
placed  until  it  becomes  attached  to  the  cortex.  The  deposits 
seem  to  be  laid  down  in  layers,  and  the  mass  does  not  have 
normal  bone  structure.  It  cannot  be  looked  upon  as  a  true 
exostosis.  This  type  is  seen  most  frequently  in  the  second 
age  period. 


CHAPTER  XI 
BONE  TUMORS 


CHAPTER  XI 
Bone  Tumors 

BEFORE  discussing  bone  tumors,  reference  must  again  be 
had  to  the  normal  bone,  as  a  correct  diagnosis  depends 
upon  variations  of  its  constituent  parts  from  the  normal. 
A  long  bone  is  composed  of  an  outside  fibrous  sheath  called 
periosteum,  not  demonstrable  by  the  A-ray  in  its  normal 
condition.  Beneath  it  is  a  dense  compact  bone  known  as  cortex, 
composed  of  bone  cells  and  masses  of  inorganic  salts  traversed 
by  numerous  small  canals.  Within  is  the  medullary  canal  con- 
taining the  marrow,  fat,  nerves,  bloodvessels  and  lymph 
channels.  At  the  ends  of  the  bone  the  cortex  and  medullary 
canal  merge  into  fmely  reticulated  bone  forming  the  cancellous 
ends,  and  these,  in  turn,  are  covered  by  cartilage  forming  the 
joint.  The  bone  is  pierced  halfway  between  the  ends  by  a 
small  canal  perpendicular  to  the  shaft.  The  canal  is  the  point  of 
entrance  for  the  nerves,  blood  and  lymph  vessels.  Since  the 
malignant  cells  are  carried  by  either  the  blood  or  lymph,  this 
nutrient  canal  plays  a  very  important  part  in  metastatic 
maHgnancy. 

In  the  diagnosis  of  bone  tumors  the  essential  thing  is  to 
determine  whether  the  growth  is  mahgnant  or  not.  If  that 
point  can  be  established  the  surgeon  will  be  given  the  informa- 
tion that  is  necessary  for  him  to  determine  the  character  of  the 
operation  to  be  performed.  It  is,  however,  still  better  if  the 
roentgenologist  can  go  further  and  determine  the  exact  nature 
of  the  lesions. 

With  the  exception  of  the  cartilage  any  one  or  all  of  the 
constituent  parts  of  the  bone  may  be  involved  by  neoplastic 
growths.  In  the  chapter  on  joint  lesions  it  was  pointed  out  that 
cartilage  is  quite  easily  attacked  by  an  infection,  but  is  quite 
resistent  to  tumors,  and  is  seldom  if  ever  involved  by  them. 
1^  241 


242  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

Attention  has  been  repeatedly  called  to  the  fact  that  the  only 
direct  changes  that  can  be  seen  upon  an  x-ray  plate  are  bone 
destruction  and  bone  production,  and  that  it  is  the  variation 
in  these  two  processes  that  yields  certain  data  upon  which  to 
formulate  a  diagnostic  hypothesis.  In  addition,  as  we  have 
mentioned,  there  are  two  accessory  aids  of  great  value — age 
and  sex.  One  does  not  expect  to  find  carcinoma  in  the  young. 
If  a  malignant  tumor  is  found  in  the  bone  of  a  child  it  is  known 
that  it  must  be  sarcomatous  in  origin.  In  the  same  way  a 
malignant  growth  of  the  pelvis  of  a  female  over  fifty  years  is 
probably  a  carcinomatous  metastasis  from  the  breast,  as  that 
tumor  predominates  in  the  female,  while  in  a  male  pelvis  of  the 
same  age  the  growth  is  apt  to  be  a  metastasis  from  the  prostate, 
as  that  tumor  is  the  most  frequent  in  the  male. 

Method  of  Analyzing  Bone  Tumors.  By  studying  the 
point  of  origin  and  the  character  of  the  bone  changes 
the  writers  have  been  led  to  formulate  a  rough  outline  for  the 
analysis  of  these  various  bone  tumors.  Four  points  have  been 
taken  as  the  basis  for  classification.  They  are: 

1.  Origin  of  the  tumor. 

2.  Presence  or  absence  of  bone  production. 

3.  The  condition  of  the  cortex. 

4.  Invasion. 

At  first  glance  it  is  often  impossible  to  determine  all  four  of 
these  points,  but  if  one  or  two  of  them  can  be  established  they 
frequently  lead  to  the  correct  diagnosis. 

It  must  be  borne  in  mind  that  these  points,  which  have  been 
named  the  cardinal  points,  are  merely  methods  of  approach  to  a 
diagnosis.  If  one  such  point  can  be  established  it  automatically 
rules  in  or  out  certain  tumors,  and  will  generally  aid  in  estab- 
lishing a  second  point;  thus  eventually  all  four  will  be  estab- 
lished, and  as  each  point  eliminates  certain  tumors,  a  diagnosis 
by  exclusion  is  obtained.  As  an  example  of  this  method,  if  by 
the  first  point  it  can  be  absolutely  shown  that  the  tumor  arises 
from  the  periosteum,  that  automatically  excludes  a  carcinoma, 
as  there  are  no  primary  epithelial  cells  in  bone,  and  conse- 


BONE  TUMORS  243 

quently  if  an  epithelial  growth  develops  there,  it  must  be  carried 
in  by  the  lymph  or  blood.  Since  these  vessels  enter  the  medul- 
lary canal  by  means  of  nutrient  channels,  carcinoma  must  of 
necessity  have  its  origin  in  the  medullary  canal.  Again,  if  it 
can  be  estabhshed  that  there  is  new  bone  in  the  tumor,  that 
would  also  automatically  rule  out  round  and  spindle-celled 
sarcomata  and  carcinomata. 

In  no  lesions  of  the  bones  is  it  more  important  to  have  a 
knowledge  of  pathology  than  in  bone  tumors.  The  .v-ray  plate 
must  not  be  regarded  as  a  photograph  in  the  ordinary  sense. 
Medical  knowledge  must  be  brought  to  bear  upon  it.  The 
roentgenologist  must  I)e  familiar  with  the  growth  of  tumors; 
he  must  know  how  they  involve  the  bone  and  how  and  why 
they  metastasize.  Never  make  a  diagnosis  oj  a  tumor  because  it 
looks  like  something  that  has  been  seeyi  before.  The  diagnosis 
must  be  made  upon  the  fundamental  facts  of  pathology  which 
have  been  translated  into  shadows  and  registered  upon  the 
plate.  After  the  diagnosis  is  made,  the  reasoning  must  then  be 
reversed,  and  each  pathok)gicaI  point  of  the  tumor  in  question 
apphed  to  the  plate,  and  they  must  fit  in.  If  they  do  not  the 
diagnosis  is  probably  incorrect.  This  point  cannot  be  em- 
phasized too  strongly. 

These  four  cardinal  points  may  now  be  examined,  bearing 
in  mind,  however,  that  they  are  merely  methods  of  approach, 
and  that  while  they  will  help  in  the  vast  majority  of  cases,  yet 
like  all  other  methods  of  medical  classifications  they  are 
not  infallible. 

Point  of  Origin.  By  point  of  origin  is  meant  the  position 
where  the  growth  arises  whether  in  the  medullary  canal  (Fig. 
250)  or  whether  it  springs  from  the  cortex  or  periosteum.  Fig. 
251.  The  cartilaginous  articulating  surfaces,  are  not  included, 
as  tumors  do  not  arise  from  them.  If  this  can  be  determined  one 
point  of  differential  diagnosis  is  established.  All  tumors  in  bone 
must  be  either  primary  or  metastatic.  It  has  already  been 
mentioned  that  there  is  no  primary  epithelial  tissue  in  bone, 
and  that  if  carcinoma  is  present  it  must,  by  means  of  the  vessels 


244  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  250. — A    tumor    arising    within    the    medullary    canal.    (Giant-cell 

sarcoma.) 


BONE  TUMORS 


245 


Fig.  251. — A  tumor  arising  from  the  cortex.  (Fibromyxonia.) 


246  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

through  the  nutrient  canal,  have  lodged  in  the  medullary  canal 
and  grown  there.  So  carcinoma  must  always  be  metastatic 
in  origin,  and  must  arise  in  the  medullary  canal. 

Since  sarcoma  is  of  connective  tissue  origin,  it  may  be 
either  primary  in  the  medullary  canal  or  metastatic  in  origin. 
It  is  also  known  that  enchondromata  may  be  either  cortical 


Fig.  252.— Bone   production    within    a   tumor.    (Osteoma.) 

or  [medullary  in  origin,  while  bone  cysts  are  nearly  always 
medullary  in  origin  and  very  rarely  cortical. 

Periosteal  and  osteosarcomata  are  cortical  in  origin,  as 
well  as  osteomata.  Ossifying  hematomata  are  not  bone 
growths,  yet  clinically  may  simulate  them  and  so  they  have 
been  classed  among  tumors  and  they  may  be  looked  upon  as 
periostial  in  origin.  Sometimes  when  the  growths  have  become 
very    extensive    it    is    impossible   to   determine   their   origin. 


BONE  TUMORS  247 

While  this  cardinal  point  hmits  the  numfDcr  of  tumors,  some 
having  been  cxchided  by  their  points  of  origin,  one  is  still 
tar  from  a  diagnosis.  The  second  cardinal  point,  therefore,  is 
brought  to  bear  upon  the  problem. 

Boiie  Production.  Bone  production  docs  not  take  place 
in  cither  carcinoma  or  in  round-cell,  spindlc-cell,  or  giant-cell 
sarcomata.  Consequently  if  it  can  be  cstabHshcd  definitely 
that  there  is  bone  production  within  the  tumor  the  above 
mentioned  growths  can  be  ruled  out,  Fig.  2^2.  That  in  turn 
w^ill  again  limit  the  tumors  to  osteoma,  osteochondroma, 
periosteal,  and  osteosarcoma,  and  ossifying  hematoma.  Bone 
cysts  are  not  bone  producers,  but  since  they  are  so  frequently 
accompanied  by  fracture,  bone  production  hiid  down  as  the 
repair  of  the  fracture  may  be  at  times  confusing.  After 
determining  that  the  tumor  contains  new  bone  procUiction 
it  must  then  be  considered  what  is  the  character  of  the  new 
bone;  is  it  laid  down  in  any  definite  way?  All  the  bone  pro- 
ducing tumors  are  either  cortical  or  periosteal  in  origin  and  in 
their  growth  extend  out  into  the  soft  tissues.  In  this  region 
bone  production  is  best  studied,  as  here  it  has  free  growth, 
not  being  confined  or  hampered  by  the  bone  nor  can  the  new 
l3one  growth  be  confused  with  the  bone  itself,  as  might  be 
done  if  the  JDone  production  in  that  portion  of  the  tumor  lying 
within  the  bone  were  considered.  Close  inspection  of  this  new 
bone  gives  the  rather  starthng  information  that  in  malignant 
growths,  JDone  is  laid  down  in  long  striae  practically  perpen- 
dicular to  the  shaft,  while  in  benign  grow^ths  (with  the  ex- 
ception of  an  osteoma)  the  growth  of  new  bone  is  more  or  less 
parallel  to  the  shaft. 

This  second  cardinal  point  helps  materially  in  diagnosis  by 
the  process  of  elimination.  But  there  still  remain  a  number  of 
tumors  which  must  be  diagnosed,  particularly  those  of 
medullar}^   origin,   so   the   third   cardinal   point   is   involved. 

Cortex.  It  must  be  determined  whether  the  cortex  is 
present  or  absent,  and  if  present  whether  it  is  expanded  in  a 
spherical  or  longitudunal  manner.  W  hen  considering  the  diag- 


248  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

nosis  of  tumors  based  upon  the  first  two  cardinal  points  the 
tumors  have  been  spoken  of  as  arising  from  the  cortex  and  per- 
iosteum, and  the  production  of  bone  in  them  has  been  mention- 
ed; but  it  is  well  to  check  them  up  again  with  this  third  point. 
The  condition  of  the  cortex  is  also  a  verj'  important  factor. 
Experience  has  shown  that  benign  tumors  arising  in  the 
medullary  canal  are  slow  growing  and  always  take  the  path  of 
least  resistance;  that  is,  while  they  grow  slowly  toward  the 


Fig.  253. — Benign    tumor    extending  up  and  down  the  medullary  canal 
with  shght  expansion  of  the  bone.  (Cyst.) 


cortex  they  progress  more  easily  up  and  down  the  shaft.  The 
pressure  from  the  growth,  however,  causes  an  expansion  of 
the  cortex,  but  the  expansion  is  always  spindle-shaped  (Figs. 
253  and  254),  or  cylindrical,  and  the  cortex  is  intact  unless 
the  growth  is  unusuallj'  large.  On  the  other  hand  in  malignant 
conditions,  the  growth  is  spherical  in  nature  and  extends 
equally  in  all  directions.  On  account  of  the  rapid  growth  of  the 


BONE  TUMORS 


249 


Fig.  254. — Benign   tumor   of  the  fibula.  Note  the  extension  within  the 
medullary  canal  and  expansion  of  the  cortex.  (Cyst.) 


250  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

tumor,  the  cortex  docs  not  expand,  but  the  growth  involves 
and  destroys  it,  so  that  in  this  lesion  the  cortex  is  absent.  Fig. 
255.  In  the  early  stages  of  such  a  tumor  the  growth  has  not 
reached  the  cortex  and  it  is  intact;  however,  since  at  this  time 
there  will  be  no  symptoms,  the  lesion  will  not  be  seen  in  this 
stage.  It  is  only  after  pressure  symptoms  begin  that  the  patient 


Fig.  255. — Complete    destruction    of   the    head.    The   cortex   destroyed. 

(Round-cell  sarcoma.) 

presents  himself  for  examination.  Then  these  cortical  changes 
are  discovered.  There  is  only  one  exception  to  this  and  that  is 
the  giant-cell  sarcoma,  Fig.  256.  As  the  name  implies  it  belongs 
to  the  sarcomatous  group,  but  on  account  of  the  character  of  its 
cells,  metastasis  is  almost  impossible,  so  that  practically  a 
benign  condition  is  dealt  with. 


BONE  TUMORS 


2.;  I 


The  fourth  cardinal  point,  invasion,  is  still  to  be  considered. 

Invasion.  This  point,  frequently  the  hardest  to  determine, 
is  the  most  important  of  all.  If  it  can  be  definitely  established 
that  the  growth  is  invasive,  by  that  meaning  that  it  infiltrates 
into  bone  and  soft  tissue,  everything  is  in  reality  determined, 
because  maligiiamy  depends  upon  invasion,  Fig.  257. 


Fig.  256. — Marked  expansion  of  the  cortex  from  a  medullary  tumor.  Cortex 
thinned  out,  but  still  visible.  (Giant-cell  sarcoma.) 

After  determining  these  four  cardinal  points  it  is  then  well 
to  take  up  what  might  be  termed  the  three  laws  of  probabilities. 
By  these  laws  is  meant  what  is  most  frequently  found  when 
the  age  and  the  sex  of  the  patient  are  taken  into  consideration 
with  the  particular  bone  involved. 

Law  as  to  Age.     It  is  known  that  certain  tumors  arc  most 


252  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  25-. — Metastatic    carcinoma  showing  invasion.   Primary  gro\\'th  in 

the  urinary  bladder. 


BONE  TUMORS  253 

common  at  some  age  periods  and  arc  very  rare  at  others. 
Carcinoma  is  quite  common  over  forty  years,  that  is  in  the 
third  age  period,  w  hile  it  is  cxtremels  rare  in  children,  that  is  in 
the  first  age  period,  and  is  seen  only  occasionally  between 
twenty  and  forty  years,  the  second  age  period.  Sarcoma, 
however,  may  occur  at  any  age,  but  it  is  most  common  in  the 
first  and  second  age  periods.  A  malignant  liimor  of  the  first  age 
period  would  then  be  by  this  law  a  sarcoma  rather  than  a 
carcinoma. 

Laic  as  lo  Sex.  The  (irsl  law  demonstrates  thai  carcinoma 
is  a  lesion  found  most  Irequentlx  in  the  third  age  j^eriod; 
it  is  also  known  that  of  all  growths  in  the  female  at  that  period, 
carcinoma  of  the  breast  is  by  far  the  most  common.  So  in  an 
elderly  female,  by  this  law,  any  grow  th  in  a  bone  is  most  apt  to 
be  carcinomatous  in  origin. 

Law  as  to  Bone  Involvement.  It  has  already  been  stated 
that  carcinoma  is  a  metastatic  growth,  while  sarcoma  may  be 
either  metastatic  or  primary  in  origin.  Since  carcinoma  enters 
the  bones  by  means  of  the  nutrient  canal  it  generally  metas- 
tasizes close  to  the  entrance  of  this  canal,  w  hile  in  sarcoma  the 
favorite  site  for  the  grow  th  is  at  the  ends  of  the  bcjne;  so  again 
by  this  law  a  medullary  growth  near  the  middle  of  the  bone  will 
probably  be  a  carcinoma.  Again  a  growth  in  an  elderly  female 
in  the  thoracic  spine  is  aj^t  to  be  carcinomatous,  lirst  on  account 
of  sex,  then  on  account  of  age,  and  finally  because  ol  all 
thoracic  spine  growths  carcinomatous  metastases  (^f  that 
region  are  by  far  the  most  frequent. 

Before  attempting  to  describe  the  si^ecilic  h-sions  of  the 
more  common  growths,  it  is  of  interest  to  dwell  brielly  upon 
how  malignant  and  benign  tumors  grow  and  their  relation  to 
normal  bone.  \\  hen  a  malignant  grow  th  starts  in  the  medullary 
canal  it  grows  l)\  cell  division.  Starting  from  a  central  point  it 
grows  equally  in  all  directions;  conseciuently  such  a  growth 
is  spherical  in  shape.  It  grows  as  a  mass  so  rapidly  that  the 
surrounding  bone  is  killed  by  pressure  and  absorbed;  the  cortex 
does  not  have  time  to  expand,  but  is  destroyed.  \\  hile  it  is  true 


254  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

that  it  does  extend  down  the  medullary  canal,  still  as  a  whole  it 
is  spherical  in  shape.  It  does  not  penetrate  the  Haversian 
canals  and  does  not  pierce  the  cortex  but  destroys  it.  Since  it 
grows  as  a  mass  it  is  limited  as  a  mass  to  one  section  of  the 
bone,  and  does  not  break  out  in  the  same  bone  at  another  point 
leaving  normal  bone  in  between.  Immediately  one  sees  the 
fundamental  differences  between  it  and  an  inflammatory 
lesion  such  as  osteomyelitis.  In  the  latter  condition  the  infec- 
tion spreads  by  means  of  the  Haversian  canals,  and  conse- 
quently destruction  of  bone  may  occur  at  various  places 
with  normal  bone  between.  \\  hen  the  infection  reaches  the 
cortex  it  breaks  through  in  one  or  two  places,  leaving  normal 
cortex  between.  This  breaking  through  the  cortex  relieves  the 
pressure,  and  the  cortex  will  not  be  destroyed  en  masse  as  in 
growths.  In  all  malignant  tumors  except  periosteal  and  osteo- 
sarcoma there  is  no  new  bone  production  within  the  tumor 
or  in  the  bone  adjacent  to  it.  In  osteomyelitis  when  the  in- 
fection subsides  there  is  new  bone  production  at  the  edges  of 
the  infected  area,  this  being  nature's  way  of  limiting  the  in- 
fection. This  reaction  does  not  take  place  with  malignant 
growths.  The  question  naturally  arises:  Why  is  bone  produc- 
tion not  seen  under  such  conditions? 

It  must  be  remembered  that  to  produce  bone  there  must  be 
a  source  of  stimulation,  and  that  any  foreign  element  intro- 
duced into  normal  bone  will  produce  such  a  reaction  provided 
sufficient  time  elapses  for  the  new  bone  to  form.  In  osteo- 
myelitis the  infection  is  a  foreign  element,  but  in  the  acute 
stages  new  bone  is  not  encountered. 

The  infection  travels  too  rapidly,  and  sufficient  time  does 
not  elapse  to  allow  the  new  bone  to  form,  because  the  point  of 
stimulation  is  just  where  the  infection  stops  and  normal  bone 
begins.  In  a  virulent  infection,  on  account  of  its  rapid  spread, 
its  point  of  contact  with  normal  bone  is  constantly  changing 
its  position,  and  nature  docs  not  have  sufficient  time  to  lay 
down  new  bone  because  the  infection  passes  over  that  point 
and  a  new  contact  point  is  established.  It  is  like  attempting  to 


BONE  TUMORS  iss 

build  a  dam  by  throw! ng  in  earth  in  a  rapidly  moving  stream. 
The  moment  the  infeetion  subsides,  however,  its  point  of  con- 
tact with  normal  bone  remains  practically  stationary,  and 
nature  then  has  sudicient  time  to  lay  down  her  dam  of  new 
bone  and  limit  the  spread  of  infection.  In  maHgnancy  there  is 
the  rapid  growth  similar  to  the  acute  infection;  but  the  great 
difference  is  that  at  no  stage  does  the  rapid  growth  of  the  tumor 
cease  as  in  an  infection,  for  that  reason  in  no  j^eriod  ot  the 
grow'th  of  the  tumor  has  nature  sufficient  time  at  her  disposal 
to  lay  down  a  protective  dam  of  new  bone.  Just  as  in  an  infec- 
tion, the  point  of  stimulation  is  the  point  of  contact  between 
the  tumor  and  the  normal  bone. 

In  benign  growths  occurring  within  the  medullary  canal  a 
totally  different  condition  arises.  While  the  growth  starts  at  a 
central  point  as  a  spherical  mass,  it  grows  but  slowly,  and 
when  it  comes  in  contact  with  the  walls  of  the  bone  it  expands 
very  slowly  in  a  lateral  direction  but  extends  up  and  down  the 
medullary  canal.  Its  pressure,  however,  extended  laterally, 
slowly  expands  and  thins  out  the  cortex  but  does  not  destroy  it 
as  in  malignant  growths.  With  the  expansion  of  the  cortex  go- 
ing on  very  slowly  there  is  probably  at  the  point  ol  contact 
some  new  bone  laid  down,  just  a  sufficient  amount  to  counter- 
act the  slow  pressure  destruction  from  the  tumor.  \\'ith  the 
growth  of  the  tumor  the  point  of  contact  is  slowly  pushed  out. 
The  result  is  an  expanded  but  thinned  cortex.  Since  the 
growth  extends  down  the  canal  the  expansion  will  not  be 
spherical  but  cylindrical  in  shape.  The  point  of  contact  at  the 
edge  of  the  tumor  in  the  medullary  canal  will  also  show  a  thin 
line  of  bone  definitely  limiting  the  growth;  but,  as  in  the 
gradual  spreading  of  the  cortex,  this  thin  lineot  bone  will  also 
slowly  change  its  position. 

The  following  are  the  chief  characteristics  of  the  more 
important  bone  tumors: 

Carcinoma.  This  is  essentially  an  old  age  tumor.  It  is 
always  metastatic  in  origin,  and  since  it  enters  by  means  of  the 
nutrient  canal  it  is  most  frequently  seen  at  the  middle  point 


256  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  258. — Metastatic  carcinoma  showing  invasion.  Primary  growth  in 
the  breast.  Note  the  pathological  fracture.  Impossible  to  differentiate 
the  points  where  the  tumor  ends  and  the  normal  bone  begins. 


BONE  TUMORS 


257 


Fig.  259. — Small  carcinomatous  metastases  of  the  skull  from  a  breast  tumor. 

of  the  bone,  Fig.  258.  Since  it  is  epithelial  in  origin  there  is 
no  bone  production  within  the  tumor,  and  on  account  of  its 
rapid  growth  there  is  no  new  bone  reaction  external  to  it. 
It  grows  equally  in  all  directions  as  a  solid  mass,  does  not 
expand  the  cortex  but  destroys  it  completely,  and  shows  dis- 
tinct signs  of  invasion  in  the  medullary  canal  and  soft  tissues. 

In  the  female,  carcinoma  of  the  breast  is  the  most  common, 
and  its  metastases  are  seen  in  the  order  of  tluir  I  requency  in  the 
ribs,  thoracic  spine,  lumbar  spine,  ilia,  femur,  especially  the 
greater  trochanter,  skull  (Fig.  259)  and  humerus.  It  is  almost 
an  axiom  that  carcinoma  of  the  breast  never  metastasizes 
below  the  elbow  and  knee. 

Carcinoma  0/  the  ovaries  and  uterus  seldom  metastasizes 
to  bones,  but  in  our  series  of  cases  the  writers  have  had  two 


258  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

metastases  of  the  tibia  from  careinoma  of  the  urinary  bladder. 
Whether  the  tibiae  are  the  favorite  sites  for  such  lesions  it  is 
impossible  to  say,  as  two  cases  are  too  few  upon  w^hich  to  base 
conclusions.  In  the  male,  carcinoma  0/  the  tongue  and  lip  are 


Fig.  260. — Carcinoma  of  the  mandible,   secondary  to  carcinoma  of  the 

tongue. 

most  common  and  frequently  involve  the  mandible  by  direct 
extension,  Fig.  260. 

Carcinoma  of  the  prostate  is  also  very  common  and  the  bones 
are  very  frequently  involved.  Fig.  261  and  262.  The  bone 
changes  differ  slightly  from  those  in  other  types  of  carcinoma, 
but  when  once  seen  will  always  be  recognized,  as  the  changes 
are  quite  typical.  Since  this  type  of  tumor  grows  very  slowly, 
production  of  new  bone  is  not  found  within  the  growth  but 
just  at  the  edge  of  the  growth  in  the  normal  bone,  in  other 
words  at  the  point  of  stimulation.  Consequently,  these  meta- 
stases seem  to  be  more  or  less  encapsulated  in  a  calcium  wall, 
as  nature  attempts  to  limit  the  growth.  There  are  also  irregu- 
lar areas  of  increased  density  of  calcium  salts  throughout  the 
bone  where  no  gross  malignancy  can  be  demonstrated.  This 
may  be  due  to  malignant  infiltration  too  small  to  be  recognized 
upon  the  plate  and  yet  sufTicient  to  produce  bone  reaction. 
When  a  pelvis  is  so  involved  it  sometimes  appears  as  if  the 


+-> 


26o  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  262. — The  marked  density  of  the  lumbar  vertebrae  with  mihary  pro- 
static metastases.  This  density  is  due  to  growth  of  new  bone  around 
the  small  metastases.  The  fourth  hmibar  vertebra  has  also  been  shghtly 
compressed.  The  individual  metastases  are  too  small  to  be  seen. 


BONE  TUMORS 


261 


lesion  were  that  of  Pagct's  disease.  The  l)ones  most  commonly 
affected  are  the  pelvic  bones,  sacrum,  lower  lumbar  vertebrae, 
femur  and  occasionally  the  scapula  and  clavicle.  Just  as  in 
carcinoma  of  the  breast,  when  the  long  bones  are  involved, 
pathological  fractures  are  frequent.  This  growth  is  essentially 
a  lesion  of  the  third  age  period. 


I 


Fig.  263. — Round-cell  sarcoma  of  tlu-  humerus.  Tlie  condition  cannot  be 
differentiated  from  carcinoma  except  by  the  i)osition  of  the  tumor  in 
the  bone  and  the  absence  of  a  primary  carcinomatous  growth.  Note 
the  destruction  of  the  cortex  with  no  expansion  of  bone. 


Hypernephroma.  This  is  also  of  medullary  origin  and 
gives  the  same  x-ray  appearance  as  carcinoma.  In  fact  it  is  im- 
possible to  differentiate  it  from  any  medullary  non-bone- 
producing  growth.  It  does  not  metastasize  to  bone  with  great 
frequency,  but  when  it  does  the  bones  of  the  upper  part  of 
the  body  are  involved,  particularly  the  humerus.  It  is  a  lesion 


262  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


of  the  latter  part  of  the  second  and  the  first  half  of  the  third 
age  period. 

Round-cell  SARCO^L\.  Like  carcinoma  this  lesion  (Fio;. 
263)  is  also  very  malignant.  It  is  medullary-  in  origin,  expanding 
equally  in  all  directions,  contains  no  bone  within  the  growth, 
does  not  expand  the  cortex  but  destroys  it  and  is  invasive. 

As  far  as  the  growth  is  con- 
cerned it  cannot  be  differenti- 
ated from  carcinoma  upon  an 
A-ray  plate.  It  may  occur  at  any 
age  period,  but  is  especially 
common  in  the  first  and  second 
age  periods.  To  make  a  differ- 
ential diagnosis  between  such  a 
lesion  and  carcinoma,  indirect 
evidence  must  be  relied  upon, 
namely,  the  laws  of  probability. 
By  the  law  relating  to  age, 
if  the  tumor  is  in  the  first  age 
period  and  the  first  half  of  the 
second  period  the  lesion  will 
be  sarcomatous  in  origin.  In  the 
third  age  period  the  law  does 
not  help  us  materially,  as  both 
types  of  gro\\"th  occur. 
Fig.  264.— Spindle-cell  sarcoma  .  ^y  ^he  law  relating  to  sex  it 
of  the  tibia  with  marked  is  known  that  carcinoma  of  the 
periosteal  reaction.  breast  is  by  far  the  most  com- 

mon, and  consequently  the 
growth  is  more  apt  to  be  carcinomatous.  \\  hile  prostatic  car- 
cinoma is  also  quite  common,  yet  its  bone  lesions  are  typical 
and  it  has  an  identity  of  its  own. 

B}'  the  law  relating  to  bone  involvement,  since  carcinoma 
is  metastatic  entirely,  the  lesion  is  more  apt  to  be  near  the 
entrance  of  the  nutrient  canal.  \\  hile  sarcoma  may  occur  in 
any  portion  of  the  bone,  as  the  primary  elements  are  through- 


BONE  TUMORS  263 

out  the  bone,  yet  the  great  majority  of  the  lesions  are  at  the 
ends.  Then  too  eareinoma  is  but  rarely  seen  below  the  elbow 
and  knee,  and  lesions  of  bones  below  these  two  joints  are  con- 
sequently more  apt  to  be  sarcomatous  in  origin. 

Spindle-cell  Sarcoala.  While  spindle-cell  sarcoma  is 
malignant  it  does  not  seem  to  be  as  invasive  when  seen  upon 
an  x-ray  plate.  It  destroys  equally  in  all  directions  is  generally 
medullary  in  origin,  does  not  expand  the  cortex  but  destroys 
it.  The  growth,  however,  does  not  show  the  same  degree  of 
invasion  and  may  be  mistaken  for  osteomyelitis.  Fig.  264. 
It  gives  the  appearance  of  being  slightly  limited  in  its  extension 
through  the  medullary  canaL 

Periosteal  and  Osteosarcoma.  These  growths  have 
probably  the  same  origin  but  they  give  such  a  different  picture 
upon  the  plate  that  they  will  be  described  separately. 

Periosteal  sarcoma  (Figs.  265,  266  and  267),  as  its  name 
implies,  arises  from  the  periosteum.  It  is  a  bone-producing 
tumor,  but  the  major  portion  of  the  bone  is  laid  down  in  the 
soft  tissues.  The  shaft  and  periosteum  show  but  little  destruc- 
tion; occasionally  the  cortex  may  look  a  trifle  irregular  and 
worm  eaten.  It  is  probably  the  most  characteristic  of  all 
tumor  growths,  and  when  the  peculiar  way  in  which  the  new 
bone  is  laid  down  is  once  recognized,  a  mistake  in  diagnosis 
will  seldom  be  made.  Small  striae  of  calcium  salts  are  laid 
down  approximately  perpendicular  to  the  shaft,  but  not  quite 
reaching  the  cortex.  In  other  words  the  lines  of  bone  are  laid 
down  in  the  tumor  and  apparently  are  not  connected  with  the 
periosteum.  They  resemble,  roughly,  the  picture  of  the  rays  of  a 
sunset.  In  this  tumor  the  greatest  growth  is  in  the  soft  tissues, 
and  the  bone  changes  are  entirely  outside  of  the  bone  proper. 
This  lesion  is  seen  most  frequently  in  the  first  age  period  and 
the  first  half  of  the  second  age  period. 

Osteosarcoma  (Fig.  268)  arises  from  the  cortex,  and  extends 
out  into  the  soft  tissues  as  well  as  involving  the  bone.  It  is 
frequently  impossiJDle  to  determine  where  it  arises,  as  both 
cortex  and  apparently  the  medullary  canal  are  involved.  It  is  a 


264  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  26^. — Periosteal    sarcoma.    An  advanced    case    where    the    shaft     is 

involved. 


Fig.   266. — Periosteal  sarcoma  showing  the   faint  bone  striae  in  the    soft 
tissue  perpendicular  to  the  shaft. 


BONE  TUMORS 


265 


Fig.  267. — Periosteal   sarcoma  showing  perpendicular   bone   striae  in  the 

soft  tissues. 


Fig.  268. — Osteosarcoma   showing  the  dense  bone  production.  Note  the 
perpendicular  arrangement  of  the  bone  at  the  edges  of  the  growth. 


266  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

bone-produciiig  tumor,  and  the  amount  of  bone  produced 
depends  upon  the  mahgnancy  of  the  individual  tumor.  In  the 
more  malignant  type  there  is  but  little  new  bone,  while  in  the 
slow  growing  type  there  is  marked  bone  production.  Like 
periosteal  sarcoma  the  growth  extends  out  into  the  soft  tissues, 
but  unlike  periosteal  sarcoma  there  is  extensive  destruction  of 
the  shaft.  The  new  bone  is  laid  do\^  n  in  perpendicular  striae 
and  is  connected  with  the  shaft.  When  it  is  laid  down  massiveh'. 


Fig.  269. — Giant-cell  sarcoma.  Note  the  expanded  but  intact  cortex  and 
sharp  demarcation  of  the  tumor  in  the  medullary  canal. 

stalagmites  of  new  bone  arise  from  the  bone  mass  hke  church 
spires  piercing  a  city's  sky  line.  Of  all  the  malignant  growths 
these  are  the  only  two  tumors  that  produce  bone  within 
themselves.  This  lesion  is  most  frequent  in  the  first  age  period 
and  the  first  half  of  the  second. 

Myeloma.  Alyeloma  is  a  malignant  tumor  which  is  seen 
only  occasionally.  It  is  slow  growing  and  consequently  does  not 
belong  to  the  more  mahgnant  class.  Its  favorite  site  is  the  flat 


BONE  TUMORS 


267 


bones,  though  the  long  ones  may  be  in\'oIvcd.  The  cardinal 
points  cannot  be  applied  as  a  whole  in  the  diagnosis  of  this 
tumor.  It  is  a  multiple  lesion,  and  the  bones  are  pierced  by 
small  focal  spots  of  destruction.  It  does  not  expand  or  destroy 
the  cortex.  There  is  marked  rarefaction  of  the  bones;  the  cortex 
may  be  thinned  out;  pathological  fractures  are  common.  It  is 
very  difficult  to  make  a  diagnosis  from  the  roentgenogram 
alone;  but  the  chnical   history    and   the  presence  of  Bence- 


FiG.  270.  Fig.  2-1. 

Fig.  270. — A   giant-cell   sarcoma   which    underwent   spontaneous   healing. 

The  growth  became  calcified. 

Fig.  271. — Lateral  view  of  the  same  condition. 


Jones's  bodies  in  the  urine  with  this  atypical  .v-ray  picture 
generally  lead  to  a  correct  diagnosis. 

Those  tumors  will  now  be  considered  which  arc  looked 
upon  as  benign. 

Giant-cell  Sarcoma.  Giant-cell  sarcoma  (Fig.  269)  has 
a  malignant  name  but  is  entirely  benign  in  character.  This 
tumor  is  composed  of  very  irregular  cells  w  hich  in  growing  are 


268  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

so  locked  together  that  it  is  impossible  for  one  to  break  off  and 
be  swept  away  in  the  circulation  and  lodge  elsewhere  and 
grow.  Occasionally  they  may  heal  spontaneously,  Figs.  270 
and  2-1.  After  all,  malignancy  depends  upon  two  factors — 
first,  the  ease  with  which  a  cell  may  break  loose  from  the 
parent  growth,  and  second,  the  presence  of  roads  of  transporta- 
tion, ready  to  carry  this  cell  away  and  deposit  it  in  some  other 
portion  of  the  body  where  it  grows.  The  giant-cell  .sarcoma 


Fig.  272. — Multiple  enchondromata.  These  growths  are  both  medullary 
and  cortical  in  origin.  Note  how  sharply  each  gro\nh  is  dehmited. 


starts  in  the  medullary  canal,  hence  the  roads  of  transportation 
are  there;  but  the  type  of  cell  is  such  that  it  cannot  become 
detached  from  the  parent  body.  Like  a  malignant  tumor  it 
grows  equally  in  all  directions;  but  unlike  a  malignant  tumor 
it  does  not  destroy  the  cortex  but  on  account  of  its  slow  growth 
expands  it.  There  is  no  new  bone  formation,  but  the  growth 


BONE  TUMORS 


269 


seems  reticulated.  It  is  generally  limited  in  the  medullary 
canal  by  a  thin  bony  wall  and  does  not  show  any  sign  of  inva- 
sion. Its  favorite  site  of  location  is  at  the  ends  of  the  bone. 
The  lower  end  of  the  femur,  the  upper  end  of  the  tibia  the 
lower  end  of  the  radius  and  mandible  are  most  frequently 
involved,  though  any  long  bone  may  be  attacked.  It  is  seen 
most  frequently  in  the  last  half  of  the  second  age  period  and 
at  the  beginning  of  the  third. 


Fig.  273. — Osteochondroma  of  the  head  of  the  fibula. 

En  CHONDROMA  OR  OSTEOCHONDROMA.  Enchoudroma 
(Fig.  272)  or  osteochondroma  (Figs.  273  and  274),  as  its  name 
implies,  is  cartilaginous  in  origin  and  is  generally  seen  before 
the  epiphyses  unite.  Its  early  recognition  is  probably-  due  to 
the  fact  that  pathological  fractures  are  quite  common  and  the 
patient  comes  in  for  fracture  and  the  .v-ray  then  shows  the 
tumor.  In  this  connection  it  ma\-  l)e  mentioned  that  a  fracture 


270  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  274. — Large  osteochondroma  of  the  femur. 


BONE  TUMORS  271 

through  such  a  growth  will  readily  unite,  but  since  the  growth 
is  still  present  the  fracture  will  occur  again.  Repeated  fractures 
in  the  same  area  should  always  be  viewed  with  suspicion  as 
being  pathological  from  some  growth.  The  lesion  is  seen  near 
the  ends  of  the  bone  close  to  the  epiphysis  but  not  involving  it. 
When  it  is  medullary  in  origin  it  expands  and  thins  out  the 
cortex  but  does  not  destroy  it,  and  since  the  growth  takes  the 
path  of  least  resistance,  along  the  medullary  canal,  it  is  oblong 
in  shape  and  the  cortex  is  expanded  in  a  cylindrical  manner. 
There  is  no  new  bone  formation  unless  there  has  been  a  fracture. 

The  growth  is  cystic  in  character  and  frequently  is  locu- 
lated.  These  tumors  are  supposed  to  arise  from  misplaced  bits 
of  cartilage,  that  is,  during  the  growth  of  the  bone  a  bit  of 
cartilage  at  the  epiphysis  may  be  surrounded  completely  by 
bone  but  does  not  itself  undergo  transformation.  This  condition 
probably  takes  place  in  everyone,  but  for  unknown  reasons 
the  bit  of  cartilage  will  proliferate  in  some.  As  has  just  been 
mentioned  these  misplaced  bits  of  cartilage  are  common  in 
many  bones,  and  the  stimulation,  whatever  it  may  be,  causes 
all  these  bits  to  proliferate;  consecjuently  enchondromata  are 
almost  invariably  multiple  in  origin.  They  may  also  arise  from 
the  cortex,  and  in  that  case  form  blistcrlike  lesions  in  that 
area.  Their  growth  is  always  sharply  limited,  having  a  definite 
border,  and  they  are  not  invasive.  Any  of  the  long  bones  may 
be  involved,  but  the  bones  of  the  hand  are  most  frequently 
affected.  It  may  be  mentioned  in  passing  that  malignancy  in 
the  bones  of  the  wrist,  hand,  ankle  and  foot  are  so  extremely 
rare  that  they  need  not  be  considered.  All  growths  in  these 
parts  may  be  looked  upon  as  benign.  These  tumors  are  prac- 
tically limited  to  the  first  age  period  and  are  seen  most  fre- 
quently between  the  ages  of  five  and  fifteen  j^ears. 

Cyst.  Cyst  (Fig.  275)  is  most  commonl}^  seen  at  the  same 
ages  as  the  enchondroma,  and  like  it  occurs  at  the  end  of  the 
bone  in  the  region  of  the  epiphyseal  line.  It  is  medullary  in 
origin  and  extends  up  and  down  the  shaft;  the  cortex  is  intact, 
but  is  expanded  in  a  cylindrical  manner.  It  is  sharply  limited. 


2-2  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

has  a  definite  contour  and  may  be  loculatcd,  but  is  generally 
one  large  cyst.  Cysts  are  supposed  to  be  multiple,  but  in 
the  writers'  series  of  cases  only  one  cyst  was  present  in  each 
case  though  all  the  bones  were  examined.  It  is  often  impossible 
to  differentiate  a  cyst  from  a  single  lesion  of  an  enchondroma. 


Fig.  2j^.  Fig.  276. 

Fig.  275. — Bone  cyst  of  the  humerus.  Note  the  expansion  of  the  bone 

and  the  sharp  limitation  of  the  growth.  This  cyst  is  multilocular. 
Fig.  276. — Fracture  of  the  humerus.  The  x-ray  examination  through  a 

plaster  cast  sliowed,  however,  that  this  was  a  pathological  fracture 

through  a  bone  cyst. 

The  differential  point  is  that  cysts  are  single  lesions,  while 
enchondromata  are  multiple.  Fractures  in  cysts  are  quite  fre- 
quent. Fig.  276. 

Osteoma.  Osteoma  (Fig.  277)  arises  from  the  cortex  and 
is  almost  a  solid  bone  tumor  with  small  areas  of  cartilage.  It 
extends  out  into  the  soft  tissues  entirely  and  does  not  involve 


BONE  TUMORS 


273 


Fig.  277. — Osteoma  showing  typical  cauliflower  growth. 


Fig.  2-8. — Osteoma. 


18 


2-4  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  bone,  though  attached  to  the  cortex  by  a  more  or  less  wide 
bony  pedicle.  The  bone  is  laid  down  symmetrically,  radiating 
from  the  point  of  attachment.  The  growth  is  lobulated  and 
has  a  cauliflowerlike  appearance.  The  ends  of  the  lobulation 
are  clean  cut  and  sharp  and  no  invasive  changes  are  present. 
The  growths  are  generally  multiple  at  the  point  of  origin  and 
arise  perpendicularly  from  the  shaft.  They  are  usually  seen  in 


Fig.  2t 


Fig.  279.  Fig.  280. 

Fig.  279. — Table-top  type  of  exostosis. 
-The  pencil  type  of  exostosis.  These  always  point  aA\ay  from 
the  nearest  epiphysis. 


the  first  age  period,  and  while  they  may  arise  from  any  bone 
the  favorite  sites  are  the  upper  end  of  the  humerus,  lower  end 
of  the  femur,  and  the  upper  end  of  the  tibia.  They  are  not 
painful,  and  the  patient  comes  for  examination  because  the 
mass  of  bone  mechanically  interferes  with  flexion  or  on  ac- 
count of  cosmetic  reasons. 


BONE  TUMORS 


275 


Exostoses  are  overgrowths  of  bone  arising  from  the  cortex, 
having  the  same  structure  as  the  bone,  limited  by  sharp, 
straight  borders,  and  generally  enping  in  a  more  or  less  blunt 
point.  They  are  of  two  kinds,  the  table-top  type  (Fig.  279) 
similar  to  a  broad-angled  triangle,  the  base  being  attached  to 
the  cortex;  and  the  long-pencil 
type,  arising  from  the  cortex  at  an 


Fig.  281. — Exostosis  terminating  in  a 
small  osteochondroma. 


hiG.  282.  —Fibroma  of  the 
phahinx. 


angle  and  pointing  away  from  the  nearest  epiphysis,  Figs.  280 
and  281.  Occasionally  the  end  is  capped  by  a  small  osteoma. 
They  are  benign  in  character  and  occur  most  frequently  in 
the  first  and  second  age  periods. 

Fibroma.  Fibroma  (Fig,  282)  is  a  rather  rare  tumor. 
It  is  cystic  in  character,  has  a  definite  border,  is  oval  in  shape 
extending  up  and  down  the  medullary  canal,  thins  the  cortex, 
contains  no  new  bone  and  is  not  invasive.  From  an  x-ray  stand- 
point it  cannot  be  dincrcntiated  from  a  cyst  or  cnchondroma. 


276  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

It  occurs  as  a  single  tumor  and  is  not  multiple  as  enchon- 
dromata.  In  the  only  case  observed  the  tumor  was  in  the 
phalanx  of  a  patient  in  the  first  half  of  the  second  age  period. 
Myxoma.  Myxoma  is  also  an  unusual  tumor.  The  .V-raj^ 
appearance    is    similar    to    that    of    a    cyst.     It   sometimes 


Fig.  283. — Hemangioma.    Note   the   circular  calcified  bodies  in  the  soft 
tissues.  Bones  are  not  involved. 

undergoes  malignant  degeneration.  This  tumor  occurs  in  the 
first  age  period. 

HexMangiomata  (Figs.  283  and  284)  are  lluctuating 
tumors,  cystic  in  character  ^^•hich  involve  most  frequently 
the  hands,  feet  and  forearms.  They  are  not  primarily  bone 


BONE  TUMORS 


277 


tumors,  but  since  there  is  deposition  of  calcium  salts  in  them, 
it  was  thought  well  to  describe  them.  The  .v-ray  examination 
shows  them  as  large  soft  tissue  swellings.  Lying  within* the 
tumor  are  a  series  of  round  calcified  bodies  having  concentric 
rings    within    them.    This    appearance    is    characteristic,  and 


Fig.  284. — Hemangioma  of  the  hand. 

when  once  observed  cannot  be  mistaken.  These  tumors  are 
benign  in  character. 

Ossifying  Hematoma.  This  growth  does  not  belong  to 
the  tumor  group,  as  it  is  inflammatory  in  origin ;  but  on  account 
of  the  frequency  with  which  it  is  clinically  diagnosed  as  sar- 
coma, it  seems  well  to  consider  it  under  bone  tumors.  \\  c  have 
already  discussed  this  lesion  in  connection  with  scur\y.  Since 


278  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  285. — Ossifying  hematoma  of  the  femur.      Fig. 


286.  —  Myositis 
ossificans. 


in  children  the  periosteum  is  but  loosely  attached  to  the  shaft 
of  the  bone,  hemorrhage  beneath  it  easily  separates  it  from  the 
bone  and  the  hemorrhage  will  surround  the  entire  bone,  from 
epiphysis  to  epiphysis.  In  adults  the  periosteum  is  much  more 
firmly  attached,  consequently,  the  lesion  will  be  more  or  less 
localized.  This  condition  is  the  result  of  trauma  to  the  peri- 
osteum, generally  following  a  violent  blow.  In  the  writers' 
seventeen  cases  in  adults  sixteen  were  from  injuries  received 
in  football,  and  the  seventeenth  from  the  kick  of  a  mule.  They 
all  occurred  on  the  anterior  surface  of  the  femur.  The  patients 
were  all  males  in  the  latter  part  of  the  first  age  period  and  first 


BONE  TUMORS 


279 


4 

i 


Fig.  287. — Osteosarcoma,  showing  destruction  of  tlie  bone  whicli  Is  one 
of  the  differential  points  in  distinguishing  it  from  an  ossifying  hema- 
toma. 


28o  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

half  of  the  second  age  period.  In  nearly  half  of  the  cases  a 
clinical  diagnosis  was  made  of  sarcoma. 

Apparently  what  happens  is  as  follows :  The  violent  trauma 
evidently  ruptures  a  blood  vessel  in  the  periosteum;  the 
hemorrhage  gradually  raises  the  periosteum  until  the  resulting 
pressure  becomes  greater  than  the  blood  pressure,  and  the 
hemorrhage  ceases.  A  roentgen  examination  made  shortly  after 
the  injur}'  has  been  sustained  reveals  nothing,  since  the  perios- 
teum is  not  demonstrable  in  its  normal  condition  and  the 
cortex  of  the  bone  is  never  involved.  At  the  end  of  about 
three  weeks  calcium  salts  will  be  laid  down  in  the  periosteum 
and  the  hemorrhage  beneath  it  will  undergo  organization  with 
deposition  of  calcium  salts.  Fig.  285.  The  lesion  on  account 
of  the  periosteum  will  have  a  definite  border  which  will  be  at- 
tached to  the  bone,  and  the  calcium  deposits  in  the  hemorrhage 
will  be  laid  down  more  or  less  parallel  to  the  shaft.  This  con- 
dition must  be  differentiated  from  myositis  ossificans  (Fig.  286) 
and  from  the  two  malignant  bone  tumors,  periosteal  and 
osteosarcoma,  Fig.  287. 

The  following  points  will  aid  in  the  diagnosis.  In  hematoma, 
since  the  hemorrhage  is  limited  by  the  periosteum,  there  is  a 
definite,  sharp  calcium  border.  The  shaft  of  the  bone  is  never 
involved  and  the  calcium  salts  in  the  hemorrhage  are  more  or 
less  parallel  to  the  shaft.  In  the  malignant  bone  tumors  there 
are  no  sharp  borders,  the  calcium  deposits  are  laid  down  perpen- 
dicular to  the  shaft  and  the  shaft  is  more  or  less  involved.  The 
tumor  from  hemorrhage  follows  the  shaft  and  is  generally  ob- 
long. The  malignant  tumors  are  generally  circular  in  character. 

Osteitis  Fibrosa  Cystica.  Although  osteitis  fibrosa  cystica 
is  generally  classed  with  tumors,  it  is  also  probably  of  in- 
flammatory origin.  It  is  practically  a  disease  of  the  first  age 
period.  The  femur  and  tibia  are  the  bones  most  frequently  in- 
volved. Fig.  288.  The  striking  feature  is  the  deformity  pro- 
duced by  the  softening  of  the  bones,  which  frequently  results 
in  pathological  fractures.  When  this  condition  occurs  the  lesion 
is  extensive,  involving  the  greater  portion  or  even  all  of  the 


BONE  TUMORS  281 

bone.  As  in  osteomyelitis  the  length  of  the  bone  may  be  ae- 
tually  increased.  When  the  femur  is  involved,  particularly 
the  upper  portion,  the  neck  may  be  bent  almost  to  a  right 
angle;  the  trochanter  may  be  so  high  as  to  impinge  upon  the 


Fig.  288. — Osteitis  fijjrosa  cystica,  showing  the  lengthening  of  the  tibia. 
The  bowing  is  due  to  the  softening  and  lengthening  of  the  bone.  The 
striae  of  new  bone  with  cvsts  are  characteristic  features. 


ihum,  and  abduction  be  completely  limited.  The  shaft  of  the 
femur  and  tibia  are  markedly  bowed  as  in  rickets. 

Besides  these  deformities  the  .v-ray  shows  other  marked 
changes.  The  cortex  is  expanded  and  thinned,  but  intact.  There 


282  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

are  large  cystlike  areas  in  the  medullary  cavity.  The  normal 
bone  structure  becomes  ver^^  irregular.  Long  striae  of  lessened 
and  increased  density-  occur,  enclosing  these  cystlike  formations. 
Occasionally  these  cysts  may  be  very  small  and  numerous  and 
the  striated  bone  be  the  striking  feature.   The   condition  is 


Fig.  289. — Pressure   atrophy  ul  tiie  cranial  bones  due  to  internal  pres- 
sure. This  case  was  one  of  marked  internal  hydrocephalus. 

always  definitely  limited  and  the  cysts  have  sharp  borders. 
It  is  sometimes  mistaken  for  osteomyelitis  or  sarcoma. 

Brain  Tumors.  In  discussing  the  bone  lesions  of  tumors 
it  is  advisable  to  draw  attention  to  the  changes  in  the  cranial 
bones  in  brain  tumors. 

Unfortunately  the  .v-ray  evidence  regarding  brain  tumors  is 
unreliable,  but  there  are  certain  bone  changes  occurring  in 
advanced  cases  which  must  be  noted — those  occurring  from 


BONE  TUMORS 


283 


internal  pressure,  whether  from  growth  or  Uuid,  Fig.  289. 
The  cranial  bones  become  so  much  thinned  out  in  certain 
areas,  i.e.,  over  the  convolutions,  that  in  extreme  cases  the 
plate  suggests  that  the  roentgenologist  has  actually  succeeded 
in  .v-raying  the  brain  itself.  In  hypophyseal  tumors  the  sella 


Fig.  290. — Complete  destruction  of  the  sella  turcica  from  pressure  ol  an 

hypophyseal  tumor. 


turcica  may  be  expanded  and  partiali\'  destroyed,  also  due  to 
pressure,  Fig.  290.  Brain  tumors  do  not  metastasize  to  bones. 
In  conclusion  it  must  be  remembered  that  these  growths 
and  metastases  do  not  give  the  same  appearance  in  the  flat 
bones,  such  as  the  cranial  bones  or  scapula,  and  so  the  four 
cardinal  points  cannot  be  applied  to  pathological  conditions 
in  these  regions.  In  fact  one  cardinal  point,  invasion,  is  com- 
pletely reversed.  In  metastatic  tumors  of  the  cranial  bones 
there  will  be  a  sharp  punched-out  area  with  an  abrupt  and 


284  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

definite  border,  while  in  inllammatory  lesions  the  edges  of  the 
infected  area  will  be  irregular  and  \\'orm-eaten,  suggesting 
invasion. 

Just  as  in  other  bone  lesions,  and  particularly  in  malignant 
growths,  the  roentgenologist  depends  upon  bone  destruction 
and  production  for  diagnostic  signs  and  anj^  surgical  inter- 
ference may  so  completely  change  them  that  he  will  be  com- 
pletely misled.  In  such  cases  one  should  be  extremely  guarded 
in  making  a  diagnosis,  as  the  bone  destruction  may  be  the 
result  of  surgical  interference,  and  bone  production  the  repair 
of  surgical  trauma. 

Below  is  a  summary  of  the  bone  tumors  grouped  ac- 
cording to  the  four  cardinal  points  which  aid  in  diagnosis: 

1.  Origin — Medullary  or  Cortical 

a.  Medullary 
Sarcoma 
Carcinoma 
Hypernephroma 
Myeloma 
Fibroma 

Bone  cysts 
Enchondroma 
Giant-cell  sarcoma 

b.  Cortical 
Periosteal  sarcoma 
Osteosarcoma 
Osteoma 
Enchondroma 
Ossifying  hematoma 
Bone  cysts  (rare) 

2.  Bone  Production 

Periosteal  sarcoma 

Osteosarcoma 

Osteoma 


BONE  TUMORS  285 

2.  BoxE  Production 

Ossifying  hematoma 

Enchondroma    and    bone    cyst    (where    there    has 
been  trauma) 

3.  Cortex — Expanded  or  Destroyed 

a.  Destroyed 
Sarcoma 
Carcinoma 
Osteosarcoma 
Hypernephroma 
Myeloma  (advanced  stage) 
Periosteal  sarcoma 

b.  Expanded,  hut  Intact 
Enchondroma 
Bone  cysts 
Giant-ccII  sarcoma 
Fibroma 

4.  Invasion 

All  malignant  tumors  show  invasion. 


CHAPTER  XII 
THE  SPINE 


CHAPTER  \1I 

The  Spine 

WHILE  the  spine  is  subjeet  to  the  same  injuiies 
and  diseases  as  other  bones,  yet  for  the  sake  of 
bringing  out  more  clearly  the  differential  diag- 
nosis between  the  various  lesions  it  was  thought  wise  to  devote 
a  special  chapter  to  it  as  a  whole. 

Conformation.  The  conformation  of  the  spine  is  some- 
what different  from  other  bones,  as  it  acts  as  a  housing  for 
some  of  the  most  important  structures  of  the  body — the  cord 
and  its  attendant  nerve  trunks. 

Each  individual  vertebra  arises  from  three  big  centers,  one 
for  the  body  and  one  for  each  lateral  mass,  Fig.  291.  These 
unite  to  form  one  solid  structure.  Between  each  vertebra 
is  a  cartilaginous  disc  giving  a  clear  joint  space  as  with  the  long 
bones.  On  each  side  of  the  body  are  interlocking  articulations 
preventing  any  lateral  slipping,  and  the  entire  spine  is  bound 
together  by  a  number  of  very  strong  ligaments  and  muscles. 
It  is  probably  one  of  the  strongest  structures  in  the  body, 
as  it  not  only  carries  the  weight  of  the  body  but  protects  the 
spinal  cord.  The  vertebral  i)ody  is  composed  entirely  of  can- 
cellous bone,  and  rehitively  there  is  but  little  periosteum 
present.  The  nerve  trunks  emerge  from  between  the  vertebrae. 

Divisions.  The  spine  is  divided  into  the  cervical,  thoracic, 
lumbar  and  sacrococcygeal  portions.  The  bodies  of  the  verte- 
brae increase  in  size  downward  until  the  sacrum  is  reached. 
This  is  mechanically  correct,  as  the  lumbar  \  crtebrae  have 
more  weight  to  sustain  than  the  cervical  ones. 

While  the  spine  functions  as  a  whole,  yet  the  \arious  parts 
have  slightly   different  action  and  are  slightl>-   modified   by 
other  anatomical  relations.   The  same  lesions,   therefore,   in 
different  parts  will  be  somewhat  modified. 
19  289 


290  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

The  cervical  portion,  especially  the  upper  vertebrae,  is  the 
most  flexible,  has  the  greatest  mobility  and  sustains  less 
weight,  consequently  any  lesion  in  that  portion  gives  early 
clinical  S3^mptoms  by  limitation  of  motion,  just  as  an  ordinary 
joint  would;  but  there  is  less  compression  destruction.  The 
thoracic  vertebrae  articulate  with  the  ribs,  and  these  in  turn 
are  fixed  to  the  sternum,  so  in  this  region  there  is  relatively 
little  movement;  and  while  these  vertebrae  carry  more  weight 


Fig.  291. — Showing  the  three  centers  from  which  each  individual  vertebra 
arises — one  for  the  bodv  and  one  for  each  lateral  mass. 


than  those  in  the  cervical  region,  yet  the  ribs  and  sternum  act 
as  supporting  walls,  so  that  in  the  thoracic  region  a  lesion  is 
actually  subjected  to  less  compression.  In  this  region  clinical 
symptoms  arc  not  noticeable  so  early,  and  compression 
changes  appear  more  slowly.  The  lumbar  vertebrae  have  great 
flexibility,  but  no  supporting  walls,  and,  while  they  are  the 
largest  and  strongest,  yet  a  lesion  in  them  gives  early  clinical 
signs  and  shows  marked  compression  changes. 


THE  SPINE  291 

Fifth  Lumbar  Vertebra.  The  fifth  lumbar  vertebra  is  a  very 
important  one  and  differs  from  all  others  as  to  function,  in 
that  it  is  the  end  hnk  of  a  flexible  chain  and  absorbs  the  shock 
of  the  entire  spine.  It  may  be  likened  to  a  train  of  cars  stopped 
by  a  bumper.  The  first  car  hits  its  neighbor  and  it  in  turn 
moves  forward  and  hits  the  next  one,  each  one  absori^ing  a 
certain  portion  of  the  shock;  but  the  last  car  is  against  the 
I^umper,  a  fixed  and  immovable  object,  and  so  it  stands  all  of 
the  shock  which  has  not  been  absorbed  JDy  the  other  cars.  In 
the  case  of  the  spine  the  sacrum  and  pelvis  are  the  immovable 
bumper,  and  so  the  fifth  lumbar  vertebra  has  to  take  all  the 
remaining  sliock. 

Classification'  of  Lesions.  The  lesions  of  the  spine 
ma}'  be  divided  into  age  periods  just  as  with  other  bones  and 
joints;  but  the  diagnostic  points  are  somewhat  complicated, 
because  in  a  measure  ever}-  lesion  has  to  be  considered  as  more 
or  less  affecting  both  })one  and  joint  and  must  therefore  be 
considered  together  and  not  separately,  as  a  l^one  lesion  or  a 
joint  lesion.  From  this  standpoint  our  lesions  are  divided  into: 

1.  Those  affecting  the  intervertebral  space  and  articulating 
surfaces. 

2.  Those  affecting  both  the  intervertebral  space  and  f^ody. 

3.  Those  affecting  the  body  alone. 

Before  appfying  these  cfassifications  it  will  be  wefl  to  de- 
scribe the  separate  fesions  first  and  then  see  how  this  cfassifica- 
tion  can  Idc  appfied  so  as  to  bring  about  points  of  differential 
diagnosis. 

Fractures.  These  are  but  rarely  seen  in  children.  They 
occur  most  frequently  between  the  ages  of  twenty  and  forty, 
that  is,  the  second  age  period,  fess  frequentfy  in  the  third  age 
period.  They  are  most  common  in  the  male  and  relatively  in- 
frequent in  the  female.  This  is  due  not  to  structural  weakness 
of  the  spine  but  to  the  more  active  and  hazardous  pursuits  of 
the  male.  The  body  of  the  vertebra  is  most  frequentfy  broken 
the  break  occurring  most  often  between  the  fifth  cervical 
vertebra,   and   the  second   lumbar,   increasing   in    fVequency 


292  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

from  above  downward.  In  the  cervical  and  upper  thoracic 
region  one  or  two  vertebrae  may  be  affected,  while  in  the 
lumbothoracic  region  generally  only  one  is  involved.  Frac- 
tures of  the  body  are  invariably  accompanied  by  more  or  less 
subluxation,  consequently,  dislocation  is  one  of  the  x-ray 
signs  to  be  looked  for  when  a  fracture  is  suspected. 

Fractures  of  the  cervical  region  (Fig.  292)  are  more  grave 
than   those   in   the   himbothoracic  region,  as  in  the  writers' 


Fig.  292. — Fracture  with  subhixation   of  the  second  cervical   vertebra. 


series  of  cases  the  mortality  was  higher;  fracture  of  the  laminae 
are  seen  most  frequently  in  the  cervical  region.  This  is  pro- 
bably due  to  the  fact  that  the  arch  formed  by  them  is  large  and 
also  because  from  an  x-ray  standpoint  they  are  easier  to 
demonstrate. 

Fractures  of  the  Spinous  Processes.  These  fractures  are  seen 
in  the  cervical  region.  The  processes  there  are  longer  and  more 


THE  SPINE 


293 


slender,  and  for  that  reason  are  more  easily  broken.  Fractures 
of  the  spinous  processes  of  the  thoracic  and  himbar  vertebrae 
are  either  uncommon  or  the  .v-ray  fails  to  show  them. 

Various  textbooks  state  that  fractures  of  the  transverse 
processes  are  infrequent,  but  in  the  writers'  series  they  are 
quite  common,  especially  in  the  lumbar  region.  A  fall  upon  the 
flat  of  the  back  may  fracture  all  of  them  on  one  side,  or  a 
severe  twist  may  fracture  one  or  more  processes,  Fig.  293. 


Fig.  293. — Fracture  of  tlic  transverse  process  of  tlie  lumbar  spine. 

Upon  two  occasions  the  writers  have  seen  a  fracture  of 
the  process  of  the  fifth  lumbar  vertebra  following  an  attempt 
to  make  an  extra  long  drive  while  playing  golf.  However,  it  is 
probably  not  correct  to  draw  conclusions  as  to  the  relative 
frequency  of  fractures  of  various  parts  of  a  vertebra  since  per- 
centages are  based  upon  only  such  cases  as  are  .v-rayed,  and 
then  too  there  may  be  slight  cracks  which  can  not  be  demon- 
strated. On  numerous  occasions  an  .v-ray  examination  of  the 
kidneys  has  resulted  in  the  accidental  iindiiig  of  one  or  more 


294  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  294. — Scoliosis   showing   the   primary   and   secondar\-  curves.  Note 
that  there  are  curves  but  no  angulations. 


THE  SPINE 


295 


fractured  transverse  processes.  Upon  questioning,  the  patient 
may  remember  an  injury,  but  it  was  apparently  so  trivial  as 
not  to  necessitate  medical  attention. 

There  is  no  question  but  that  many  ol  these  fractures  are 
overlooked,  and  that  if  percentages  were  based  upon  the  num- 
ber of  fractures  that  actually  occur  a  totally  different  condition 
might  be  discovered  as  to  the  relative  frequency  of  fractures 
of  the  body,  laminae  and  transverse  and  spinous  processes. 

Besides  exammmg  the  sus- 
pected area  for  fracture  the 
spine  must  be  viewed  as  to  the 
curves.  There  is  normally  a 
curve  in  the  lumbar  region  with 
concavity  outward  and  one  in 
the  thoracic  region  with  con- 
vexity outward.  There  are  no 
lateral  curves  except  in  scoliosis 
(Fig.  294);  consequentlx ,  while 
curves  are  functional,  angula- 
tions are  due  either  to  injuries 
or  to  disease.  Angulations 
always  mean  some  pathological 
process,  and  a  knowledge  of 
whether  they  point  posteriorly 
or  laterally  will  aid  in  diagnosis. 
Fig.  295.  When  the  body  of  the 
cervical  vertebra  is  broken  the 
articulating  pedicles  are  broken 
also,  and  allow  a  dislocation, 
generally  backward,  producing 

an  angulation.  The  joint  space  disappears,  and,  if  the  iVacture 
is  old,  there  w^ill  be  new  bone  formation. 

Fractures  of  the  Bodies  of  the  Thoracic  and  Lumbar 
Vertebrae.  On  account  of  the  wide  intervertebral  space  in  the 
normal,  the  changes  resulting  from  these  fractures  can  be 
more  easily  demonstrated.  The  body  is  more  or  less  compressed 


iG.  295. — Lateral  angulation  in- 
dicating a  pathological  condi- 
tion. This  case  was  a  fracture. 


296  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

and  widened  laterally,  the  intervertebral  space  is  obliterated, 
and  there  is  a  generally  lateral  angulation,  seldom  posterior 
as  in  tuberculosis.  If  the  fracture  is  an  old  one  there  will  be 
new  bone  production,  again  different  from  tuberculosis  (Fig. 
296),  as  in  that  lesion  there  is  no  bone  production. 


Fig.  296. — A  fractured  spine  with  new  bone  production. 


Diagnostic  Aids.  There  are,  then,  five  important  points 
upon  which  to  base  a  diagnosis. 

1.  Angulation. 

2.  Lateral  deformity. 

3.  Bone  production. 


THE  SPINE  297 

4.  Involvement    of   the    intervertebral    space   and    body. 

5.  Laws  of  probability  as  to  age. 

By  angulation  is  meant  a  sharp  angular  deviation;  in  the 
cervical  region  this  may  be  lateral  or  posterior,  but  in  the  tho- 
racic and  lumbar  regions  it  is  generally  lateral. 

Lateral  deformit}^  is  due  to  the  fact  that  with  fracture  the 
body  is  compressed  and  spreads  laterally. 

In  an  old  fracture  there  is  bone  production. 

The  intervertebral  space  is  always  obliterated  by  crushing. 

The  law  as  to  age  establishes  the  observation  that  fractures 
are  most  frequent  in  the  second  age  period. 

Arthritis.  This  condition  has  already  been  discussed  in 
the  chapters  on  joint  lesions,  and  while  the  same  bone  changes 
occur  in  the  spine  as  in  other  joints  there  are  certain  modi- 
fications which  must  be  noted. 

On  account  of  the  thickness  of  the  muscles  and  the  rigidity 
of  the  ligaments  it  is  not  possible  to  demonstrate  periarticular 
swelling,  and  there  is  no  fluid  present.  Atrophy,  except  in  ex- 
treme cases,  is  also  hard  to  demonstrate.  There  are  then  only 
two  processes  to  fall  back  upon,  destruction  and  bone  pro- 
duction, and  of  these  two,  bone  destruction  is  hard  to  demon- 
strate in  many  of  the  cases.  In  the  ordinary  joint  the  destruction 
of  the  cartilaginous  spaces  was  indicated  by  joint  narrowing. 
The  vertebrae,  however,  articulate  by  small  pedicles,  and  the 
bodies  are  separated  by  the  intervertebral  discs.  \\  hile  the 
cartilage  of  the  articulations  is  destroyed  yet  the  interverte- 
bral space  will  not  be  narrowed,  as  the  discs  hold  them  apart. 
Consequently  the  condition  is  not  recognized  in  the  early 
stages  but  only  in  the  stage  where  there  is  bone  production. 
One  frequently  sees  the  stiff,  rigid,  painful,  poker  back  which 
in  the  early  stages  of  the  lesion  is  shown  by  the  .v-ray  as  a 
normal  spine.  Months  later  bone  production  will  finally 
appear. 

The  first  A-ray  change  to  be  noted  w  ill  be  a  llattening  of  the 
edges  of  the  vertebrae  (Fig.  297)  where  the  lateral  ligaments 
are  attached.  Later  at  those  points  exostoses  will  form,  always 


298  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

pointing  towards  the  adjacent  bodies.  This  process  will  go  on 
until  they  actuall}'  engage,  Fig.  298. 

Infectious  Arthritis — Tuberculosis.  Just  as  in  the 
other  joints  infectious  arthritis  in  the  spine  occurs  at  any  age, 
and  the  hypertrophic  type  in  the  third  age  period,  the  latter 
type  throwing  down  more  bone  than  the  former.  These  changes 
are  all  confined  to  the  intervertebral  space,  and,  as  has  been 


Fig.  297.  Fig.  298. 

Fig.  297. — The   edges  of  the  vertebrae  are  becoming  sharpened.     This 

is  the  first  change  noted  in  an  arthritis. 

Fig.   298. — The  formation  of  exostoses  taking  place  along  the  edges  of  the 

vertebrae  and  lateral  ligaments. 

explained,  there  is  no  narrowing  of  the  joint  space  as  with 
other  joints.  Tuberculosis,  however,  is  a  notable  exception. 
In  the  first  stage  of  the  disease  there  is  destruction  of  the 
articulating  surfaces  alone.  This  stage  is  but  seldom  recognized. 
It  is  only  when  there  begins  to  be  destruction  of  the  body  with 
obliteration  of  the  space  that  this  lesion  is  recognized.  In 
the  advanced  cases  there  are  obliteration  of  the  space  and 


THE  SPINE 


299 


destruction  of  the  body.  There  is  no  new  bone  formation,  and 
in  the  thoracic  and  lumbar  regions  there  is  posterior  angulation. 
This  is  due  to  the  fact  that  the  anterior  border  of  the  body 
becomes  softened  and  then  is  crushed  by  the  body  weight, 
Fig.  299.  The  posterior  portion  of  the  body  and  the  laminae  are 
practically  never  involved,  so  that  a  lateral  .v-ray  examination 
will  show  that  the  vertebra  has  become  triangular  in  shape, 
the  apex  being  anterior  and  the  base  posterior.  This  gives  the 
characteristic  angulation  or  knuckle,  the  true  tuberculous 
kyphosis.  Therefore  in  the  noti- 
tuberculous  cases  there  is  found  : 

1.  No  angulation. 

2.  No  lateral  deformity. 

3.  Bone  production. 

4.  No  obhteration  of  joint 
spaces,  no  body  involvement. 

5.  The  condition  occurring 
at  any  age  according  to  the 
type  of  infection. 

While  in  the  tuberculous 
cases  are  found: 

1.  Angulation. 

2.  Posterior  and  not  lateral 
deformity  as  a  rule,  according 
to  where  the  lesion  is  situated. 

3.  No  bone  production. 

4.  Oi^Iiteration  of  joint  space  and  involvement  of  body. 

5.  The  condition  occurring  most  frequently  in  children  and 
young  adults. 

It  must  be  borne  in  mind  that,  as  in  other  joints,  when 
the  tuberculous  lesion  in  the  spine  becomes  a  mixed  in  lection 
then  we  have  bone  production. 

Marie-Slrumpell  Type.  Besides  the  arthritic  types  de- 
scribed there  are  two  arthritic  lesions  which  differ  markedly 
and  must  be  looked  upon  as  separate  entities.  The  Marie- 
Striimpell  type  of  spondylitis  deformans  occurs  generally  be- 


FiG.  299. — Dcstructiiin  Jilt  I  I  using 
of  two  vertebrae  witli  posterior 
angulation,  result  of  a  tuber- 
culous infection. 


300  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

twecn  the  ages  of  twenty  and  forty,  that  is,  the  second  age 
period.  It  involves  the  entire  spine,  frequently  the  hips  and 
shoulders.  It  does  not  attack  an\  of  the  other  joints.  It  starts 


Fig.  300. — Marie-Striimpell  type  ol  arthritis  deformans.  Note  the  complete 
bony  ankylosis  of  the  ligaments. 


in  the  liinibar  region  and  in\()hx\s  progressively  the  entire 
spine,  occasionally  omitting  the  axis  and  atlas.  The  shoulders 
and  hips  are  the  last  joints  to  become  affected.  It  is  a  slowly 


THE  SPINE  301 

progressing  infection  the  action  of  which  extends  over  Ncars, 
Fig.  300.  It  is  probably  infectious  in  origin,  though  this  has  not 
been  definitely  established.  In  the  early  stages  the  .v-ray  shows 


Fig.   301. — Charcot   joint    of   the    fourtli    lunibar  \crtcbra.  Note  lateral 

deviation. 


only  involvement  of  the  lumbar  region,  calcification  of  the 
ligaments  being  so  complete  as  to  result  in  actual  ankylosis, 
with  the  vertebrae  very  atrophic.  The  entire  spine  becomes 


302  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

involved,  accompanied  by  a  marked  anterior  bowing  which,  in 
extreme  cases,  is  so  pronounced  that  the  upper  portion  of 
the  spine  is  at  right  angles  to  a  line  drawn  perpendicularly 
through  the  sacrum. 

W  hen  this  state  is  reached  practically  all  the  ligaments 
have  become  calcified,  particularly  those  situated  anteriorly. 
In  fact  the  entire  spine  appears  as  if  molten  bone  had  been 
poured  over  it.  On  account  of  the  extreme  anterior  flexion  the 
anteroposterior  .v-ray  examination  shows  an  apparent  ob- 
literation of  the  joint  spaces.  This,  however,  is  due  to  the 
marked  bowing  which  causes  the  .v-ray  shadows  of  the  verte- 
brae to  overlap.  If  a  lateral  examination  is  made  each  joint 
space  will  be  seen  to  be  intact,  the  bone  change  having  taken 
place  entirely  in  the  ligaments.  In  the  early  stage  this  disease 
looks  like  the  ordinary  infectious  arthritis. 

Acute  Spondylitis  Deformans.  This  lesion  gives  an 
acute  clinical  history.  From  an  .v-ray  standpoint  it  presents 
the  same  picture  as  the  Marie-Striimpeli  type  except  that 
progress  is  more  rapid  and  that  the  joint  infection  is  not 
confined  to  the  spine,  hips  and  shoulders.  Any  joint  may  be 
involved.  This  condition  is  probably  an  atypical  form  of 
infectious  arthritis. 

Charcot  Spine  and  Syringomyelia.  Charcot  spine  (Fig. 
301)  and  syringomyelia  occurring  in  the  third  age  period 
show  practically  the  same  changes  on  the  .v-ray  plate  and 
cannot  be  distinguished  except  with  the  aid  of  the  clinical 
history.  These  lesions  are  characterized  by  the  obliteration 
of  the  intervertebral  space,  destruction  of  the  body,  lateral 
angulation,  deformity,  and  bony  detritus  lying  around  the 
destroyed  vertebrae. 

Tumors.  Tumors  in  the  spinal  column  give  the  same  .v-ray 
appearance  as  when  located  in  other  bones.  Secondary  carci- 
noma is  the  most  common  of  all.  The  lesions  of  tumors  are  all 
confined  to  the  body  alone,  and  as  has  been  so  frequently 
pointed  out  do  not  involve  the  cartilage.  Consequently^  the 
joint  space  is  intact  and  there  is  no  angulation  or  deformity  un- 


THE  SPINE 


303 


til  the  lesion  is  in  an  advanced  state.  Sarcomatous  and  earei- 
nomatous  tissue  is  relatively  dense,  and  so  the  body  weight 
compresses  it  slowly.  The  characteristic  picture  shows  the 
body  of  the  vertebra  much  narrowed,  sometimes  to  less  than 
half  the  width  of  the  other  vertebral  bodies;  the  joint  space  on 
each  side  is  intact,  Fig.  302.  Carcinoma  is  the  most  common 
lesion,  round  and  spindle-cell  sarcoma  next,  then  osteosarcoma 


Fig.  302.— Carcinoma  of  the  lumbar  \ertcbra,  showino;  the  joint  spaces 
intact  and  the  vertebra  not  compressed  at  tliis  stage. 


and  finally  osteoma  and  giant-cell  sarcoma.  Cyst  and  enchon- 
droma  have  never  been  observed  in  our  scries  of  cases. 

A  brief  description  of  these  lesions  has  only  been  given  to 
refresh  the  memory,  as  they  have  been  described  in  more 
detail  under  their  respective  heads. 

Application  of  Classification  Aids.  An  attempt  will 
now  be  made  to  show  how  diagnosis  may  be  very  materially 


304  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

helped  by  the  use  of  the  classification  given  in  the  beginning 
of  this  chapter. 

These  lesions  may  be  divided  into  three  groups : 

1 .  Those  affecting  the  intervertebral  space,  but  not  obliterating 
it.  In  these  lesions  the  body  of  the  vertebra  is  intact,  and  all 
the  changes  take  place  in  and  around  the  Joint  space.  In  this 
class  will  fall  the  various  types  of  arthritis  and  the  first  stage  of 
tuberculosis. 

2.  Those  affecting  both  the  intervertebral  space  and  body. 
Here  are  grouped  what  might  be  termed  transitional  lesions, 
as  they  are  passing  over  from  the  pure  intervertebral  space 
lesion  to  the  pure  body  lesion.  These  lesions  are  relatively  few 
in  number  and  arc  noted  in  the  destructive  stage  of  tubercu- 
losis, fracture  dislocation,  and  the  neuropathic  conditions 
such  as  Charcot  spine  and  syringomyelia.  Osteomyelitis 
should  be  placed  in  this  group,  but  it  affects  the  vertebra  so 
infrequently  that  it  can  be  disregarded. 

3.  Those  affecting  the  body  alone.  This  group  is  composed 
entirely  of  tumors. 

The  characteristic  changes  of  the  first  group  are  bone  pro- 
duction at  the  edges  of  the  vertebrae  and  in  the  ligaments,  no 
narrowing  of  the  joint  space,  no  angulation  or  deformity, 
and  occurring  at  different  ages  according  to  the  type  of  infec- 
tion. There  is  no  change  in  the  body  of  the  vertebrae  or  ob- 
literation of  the  joint  space.  There  may  be  mechanical 
ankylosis  from  the  interlocking  of  opposing  exostoses,  as  in 
hypertrophic  arthritis,  or  one  or  two  bodies  may  actually  unite 
by  means  of  deposits  in  the  lateral  ligaments,  or  there  may  be 
complete  ankylosis  as  in  acute  spondylitis  deformans  or  the 
Marie-Striimpell  type. 

The  first  stage  of  tuberculosis  falls  in  this  class  since  only 
the  cartilage  is  involved  at  this  period.  The  important  point 
to  bear  in  mind  is  that  this  group  consists  solely  of  joint 
lesions. 

The  second  group  differs  from  the  first  by  obliteration  of 
the  joint  space  and  involvement  of  the  body.  The  four  principal 


THE  SPINE  305 

lesions  arc  the  destructive  stage  of  tuberculosis,  Charcot  spine, 
syringomyelia,  and  fracture  dislocation. 

Tuberculosis  occurs  most  frequently  in  the  first  and  second 
age  periods.  If  this  disease  is  present  there  is  angulation, 
anteroposterior  deformity,  and  no  new  bone  production;  but 
fibrous  or  bony  ankjdosis  may  be  present.  In  the  neuropathic 
lesions,  Charcot  spine  and  syringomyelia,  angulation  and  lat- 
eral deformity  are  present;  new  bone  formation  is  seldom  seen, 
but  bony  detritus  is  generally  present.  These  lesions  are  seldom 
seen  before  the  third  age  period. 

In  fracture  dislocation,  angulation,  lateral  deformity,  new 
bone  production  and  bony  ankylosis  are  present.  It  is  most 
common  in  the  second  age  period. 

The  changes  in  fracture  dislocation  apply  only  to  the 
thoracic  and  lumbar  regions,  as  in  the  cervical  region  the  dis- 
placement is  generally  posterior  instead  of  lateral. 

The  third  group  is  differentiated  from  the  first  and  second 
by  the  fact  that  the  body  alone  is  involved.  This  group  is  com- 
posed of  the  tumors.  These  generally  occur  in  the  third  age 
period.  The  chief  points  are:  no  angulation  until  the  late 
stage  is  reached,  seldom  displacement,  but  narrowing  of  the 
body  with  or  ^^'ithout  bone  production  according  to  the  type 
of  lesion. 

This  classification  must  not  be  looked  upon  as  one  would 
a  rule  in  mathematics,  as  it  is  only  approximate  in  its  exactness. 
It  does  help,  how^ever,  very  materially,  as  each  point,  if 
established,  limits  the  number  of  possibilities.  The  arthritic 
group  of  spinal  lesions,  just  as  in  other  joints  lesions,  is  pro- 
bably the  one  that  offers  the  greatest  difilculty.  The  etiological 
factor  is  unknown  in  many  of  the  cases,  in  others  the  factors 
are  in  dispute,  and  finally  the  types  seem  to  overlap  clinically. 
The  same  perplexities  that  confront  the  clinician  are  equally 
applicable  to  the  roentgenologist.  In  studying  these  joint 
lesions,  the  trite  phrase  that  Osier  used  to  force  home  the  diffi- 
culties encountered  in  the  treatment  of  arthritis  upon  us  as 

students,    seems    more    and    more    applicable:    "Gentlemen, 
20 


3o6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

when  a  case  of  chronic  rheumatism  comes  in  your  front  door, 
climb  the  back  fence,  as  you  will  get  more  credit  than  if  you 
treated  the  case." 

Functional  Conditions.  Besides  fractures,  arthritis 
and  growths,  there  are  other  conditions  affecting  the  spine 
which  may  be  termed  functional. 

Scoliosis.  This  is  not  a  disease  but  a  deformity,  and  maj' 
be  the  result  of  some  abnormality  either  of  the  spine  or  of  the 
structures  connected  directly  or  indirectly  with  it.  It  some- 
times is  the  result  of  overdevelopment  of  certain  muscles,  but 
in  the  vast  majority  of  cases  the  cause  remains  undetermined. 
The  process  is  entirely  a  functional  one,  and  whenever  there 
is  a  primary  curve  there  is  a  secondary  one,  either  above  or 
below,  curving  in  the  opposite  direction  so  as  to  maintain  the 
spinal  balance. 

Some  of  the  causes  that  have  been  demonstrated  by  A'-ray 
examinations  are  as  follows:  It  has  already  been  mentioned 
that  a  vertebra  develops  from  three  principle  centers,  one  for 
the  body  and  one  for  each  lateral  mass.  There  are  several 
secondary  centers  which  appear  later,  but  they  are  not  perti- 
nent in  this  condition.  Any  overgrowth  or  faulty  development 
of  any  one  of  the  principle  centers,  but  especially  those  for  the 
lateral  masses,  will  produce  an  asymmetrical  vertebra  and  thus 
a  scoliosis. 

Occasionalh'  in  the  thoracic  region  a  rudimentary  triangu- 
lar vertebra  ma}'  be  inserted  on  one  side  between  the  adjacent 
vertebrae,  and  thus  produce  a  scoliosis.  A  single  cervical  rib 
as  well  as  the  sacrolization  of  one  side  of  the  fifth  lumbar  verte- 
bra has  also  produced  this  condition. 

\\  here  an  arm  or  leg  has  been  amputated  or  over  or  under- 
growth of  these  parts  has  occurred,  a  scoliosis  will  result.  In 
certain  trades,  such  as  hod  carrying,  where  one  side  of  the 
hod  carrier's  body  has  been  used  more  than  the  other,  scoliosis 
will  occur.  Spinal  curves  are  always  functional,  while  angula- 
tions are  pathological. 

Another    spinal   lesion   about   which    there   is   much   dis- 


THE  SPINE  30- 

cussion  is  the  so-called  sacroiliac  subluxation.  This  condition 
is  not  believed  to  be  a  real  subluxation,  but  a  ligamentous  in- 
volvement. It  is  perfectly  true  that  one  frequently  sees  one 
side  of  the  sacrum  higher  than  the  other,  suggesting  slipping, 
accompanied  at  the  same  time  by  marked  clinical  symptoms. 
Manipulation  under  anesthesia  and  fixation  by  a  plaster  cast 
will  result  in  complete  recovery,  yet  a  second  .v-ray  examination 
will  fail  to  show  any  change  at  all  in  the  position  of  the  sacrum. 
The  sacroiliac  articulation  is  one  of  the  strongest  in  the  body, 
and  its  anatomical  structure  is  such  that  only  the  most  severe 
trauma  could  cause  it  to  slip. 

While  many  cases  of  indefinite  pain  and  discomfort  in  this 
region  may  be  due  to  ligamentous  rather  than  bony  changes 
yet  it  must  be  borne  in  mind  that  there  is  at  times  a  lorward 
slipping  of  the  fifth  lumbar  vertebra.  A  lateral  view  of  the  fifth 
lumbar  and  the  top  of  the  sacrum  in  such  cases  will  show  the 
body  of  the  fifth  lumbar  projecting,  anterior  to  the  top  of  the 
sacrum.  As  an  example  of  this  condition,  a  patient  was  referred 
for  possible  kidney  stone  on  account  of  pain  and  albuminuria. 
When  the  patient  was  lying  extended  upon  her  back  there  was 
such  an  extreme  lordosis  that  after  the  kidney  examination 
a  lateral  examination  of  the  lumbosacral  region  was  made.  No 
stone  was  found,  but  there  was  anterior  slipping  of  the  lilth 
lumbar  vertebra. 

The  patient  was  placed  in  a  plaster  cast,  and  within  three 
days  the  albuminuria  and  pain  had  disappeared.  The  cast  was 
worn  a  year  and  complete  recover^'^  ensued.  Of  course  the 
subluxation  was  not  reduced;  the  cast  simply  prevented  further 
slipping  and  allowed  nature  to  tighten  up  her  ligaments  and 
adapt  herself  to  the  altered  state  of  affairs. 

Pressure  destruction  of  the  vertebrae  is  occasionally  ob- 
served, not  due  to  any  disease  but  to  direct  pressure  from 
tumors  lying  adjacent  to  the  spine.  This  is  notably  true  in 
aneurysms  of  the  thoracic  aorta,  particularly  those  arising 
from  the  descending  portion.  This  aneuiysm  lies  well  poste- 
riorl}'.  It  may  come  into  direct  contact  with  the  spine,  and  by 


3o8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

its  continued  expansion  so  press  upon  one  or  more  vertebrae  as 
to  bring  about  an  actual  pressure  necrosis.  The  same  condition 


Fig.  303. — Pressure  destruction  of  the  lumbar  vertebrae  from  a  tumor 
lying  adjacent  to  it.  When  the  tumor  \\'as  removed  there  was  com- 
plete regeneration  of  the  vertebra. 

has  been  observed  in  large  tumors  of  the  neck  and  in  tumors  of 
the  spinal  muscles,  Fig.  303. 


CHAPTER   XIII 
ABNORMALITIES 


CHAPTER  XIU 
Abnormalities 

THE  spine  is  probably  the  scat  of  more  abnormalities 
than  any  other  part  of  the  bony  structure,  and  atten- 
tion has  already  been  called  to  the  fact  that  while  these 
abnormalities  are  not  pathological  in  the  sense  ol  disease,  yet 
they  may  produce  symptoms  most  annoying  to  the  patient. 
For  convenience  it  is  well  to  consider  them  according  to  their 
locations,  namely,  cervical,  thoracic  and  lumbosacral. 

Extra  Ribs.  In  the  cervical  region  the  most  common 
abnormahty  is  the  presence  of  extra  ribs.  Fig.  304.  They  usu- 
ally spring  from  the  seventh  cervical,  and  may  be  cither  unilateral 
or  bilateral.  The  former  is  the  most  common.  It  is  present  from 
birth  although  the  symptoms — pain  and  numbness  in  the 
arm — usually  do  not  appear  until  the  second  age  period. 
The  symptoms  usually  lead  to  a  diagnosis  of  neuritis,  and  if 
the  condition  be  due  to  pressure  from  one  of  these  ribs  it  will 
not  yield  to  medical  treatment;  removal  of  the  rib  isthe  only 
cure. 

Cer\Tcal  ribs,  ho^^•ever,  may  be  present  without  pro- 
ducing any  symptoms  at  all,  and  in  those  cases  they  should 
not  be  disturbed.  When  the  abnormality  is  unilateral  the 
diagnosis  is  esisy  (Fig.  30,5),  since  the  corresponding  rib  on  the 
opposite  side  will  be  absent.  The  difficulties  arise  when  ccr\  ical 
ribs  are  present  on  both  sides.  They  may  be  mistaken  tor  the 
first  pair  of  thoracic  ribs.  This  can  be  determined  only  by  the 
examination  of  the  entire  thoracic  spine  to  ascertain  whether 
there  are  twelve  or  thirteen  pairs  of  ribs  present.  II  there  are 
thirteen  it  is  certain  that  an  extra  pair  of  cervical  ribs  are  under 
consideration.  The  seventh  cervical  vertebra  is  similar  in 
.v-ray  appearance  to  the  first  thoracic,  hence  no  conclusions 
can  be  drawn  as  to  whether  the  ribs  arise  from  the  sc\enth 

311 


312  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

cervical  or  first  thoracic  vertebra.  It  might  seem  more  simple 
to  take  the  entire  cervical  portion  of  the  spine  and  upon 
examination  see  if  there  are  six  or  seven  cervical  vertebrae 
present.  Unfortunately  this  would  not  help,  even  if  only  six 
cervicals  were  found,  because  the  attachments  of  the  ribs  are 


Fig.  304. — Rudimentary  ribs  arising  from  the  seventh  cervical  vertebra. 


variable.  They  may  be  attached  to  the  vertebrae  one  too 
high  or  one  too  low.  In  other  words,  the  first  pair  of  ribs 
may  be  attached  to  the  seventh  cervical  and  stop  with  the 
eleventh  thoracic,  or  the  first  pair  may  arise  from  the  second 
thoracic  and  stop  with  the  first  kimbar.  In  this  way  there  may 


ABNORMALITIES 


313 


be  six  cervical,  twelve  thoracic  and  six  lumbar  \  ertebrae,  or 
eight  cervical,  twelve  thoracic  and  four  lumbar  vertebrae. 
While  these  cervical  ribs  practically  always  spring  from  the 
seventh  cervical,  the  writers  have  seen  one  case  where  a  pair 
arose  from  the  second  ccr\  ical;  the  ends  being  imbedded  in  the 


•1 


£ft^ 


l^^dttl 


■^ 


m 


gr»"..-. 


Fig.  305. — Ccr\  ical  ril)  arising  from  one  side  only. 

tonsils.  The  tonsils  were  remo\cd  on  account  of  their  patho- 
logical condition,  and  at  operation  a  small  bit  of  bone  had  to  be 
removed  from  each  tonsil.  An  .\-ray  examination  after  opera- 
tion disclosed  this  curious  anomaly — a  pair  of  cervical  ribs. 

Non-union — Rudimentary  Vertebrae.  Congenital  non- 
union of  the  laminae  that  form  the  spinous  process  is  quite 
common  in  the  seventh  cer\  ical  and  occasionally  present 
in  the  sixth,  Fig.  306.  Its  importance  lies  only  in  the  fact  that 
it  is  sometimes  mistaken  for  a  fracture. 


314  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

The  abnormalities  of  the  thoracic  vertebrae  are  relatively 
uncommon,  the  most  frequent  being  the  congenital  non-union 
of  the  laminae  of  the  first  two  thoracic  vertebrae.  This  abnor- 
mality is  also  of  importance  for  the  same  reason — that  it  may 
be  mistaken  for  fracture.  Occasionally  one  sees  a  rudimentarj- 
vertebra,  triangular  in  shape,  inserted  on  one  side.  This  con- 
dition invariabh"  results  m  scoliosis,  Fig.  307.  It  generalh- 
occurs  in  the  upper  thoracic  region  and  is  important  in  that 
the  resulting  scoliosis  will  not  yield  to  the  ordinary  corrective 


Fig.  306.  Fig.  30-. 

Fig.  306. — Rudimentary  spina  bifida  of  the  seventh  cervical. 

Fig.  307. — Rudimentary  vertebra  in  the  dorsal  region,  producing  scoliosis. 

exercises.  Occasionally  such  a  vertebra  may  have  a  rudimen- 
tary rib  attached. 

Synostosis  of  the  bodies  of  two  ribs  is  quite  a  frequent 
finding.  These  are  found  independent  at  the  spinal  attachment; 
the  bodies  then  become  united,  but  iDifurcate  again  at  the 
costochondral  junction.  Fig.  308. 

Abnormalities  ix  the  Lumbosacral  Region.  In  the 
lumbosacral  region  nearl}-  all  abnormalities  are  confined  to  the 
fifth  lumbar  and  first  sacral  vertebrae.  Cong-enital  non-union 


ABNORMALITIES 


315 


Fig.  308. — Synostosis  of  the  l)()clics  of  two  ril 


)S. 


Fig.  309. — Congenital  non-union  of  the  laminae  of  the  sacrum. 


3i6  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  310. — A  pair  of  lumbar  ribs. 


Fig.  311. — Sacrolization  of  the  fifth  kimbar  vertebra. 


(Fig.  309)  is  b}-  far  the  most  common  abnormality.  In  a  series 
of  1,000  cases  of  the  lumbosacral  region  this  non-union  occurred 
in  over  15  per  cent.  These  were  not  selected  cases  with  symp- 
toms, but  were  found  in  examinations  made  for  kidne}-  and 
uretral  stones,  pcKic  fractures,  etc.  In  fact  every  plate  upon 
\\hich   this   region   occurred   was   inchided    in    the   series.    It 


ABNORMALITIES 


317 


Fig.  312. — An  attempt  at  sacrollzation  on  one  side. 


Fig.  313. — An  aberrant  articulation  ix-tween  the  clavicle  and  coraculd.  In  our 
series  of  cases  this  condition  was  seen  most  frequently  in  the  colored  race. 


3i8  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

should  not  be  mistaken  for  a  fracture.  Occasionally  a  pair  of 
extra  ribs  will  be  seen  arising  from  the  fifth  kimbar  \ertebra, 
Fig.  310. 

Another  abnormality  is  frequent — the  fifth  lumbar  takes  on 
characteristics  of  the  sacrum.  The  transverse  processes  on  one 
or  both  sides  fuse  with  the  sacrum  and  the  fifth  lumbar  be- 
comes an  integral  part  of  the  sacrum.  This  is  known  as  sacro- 
lization  of  the  fifth  lumbar  vertebrae,  Fig.  311.  Sometimes  the 


Fig.  314.  Fig.  315. 

Fig.  314. — The  ulna  is  not  seen  due  to  retarded  growth  from  a  faulty 

epiphysis.  Also  note  the  multiple  chondroma. 

Fig.  315. — An  extra  digit  arising  from  the  Httle  finger. 


processes  become  bulbous  and  have  the  shape  of  the  top  of  the 
sacrum,  but  do  not  unite.  Fig.  312.  This  may  be  spoken  of  a 
pseudo-sacrolization.  This  abnormality  generally  gives  symp- 
toms. Rudimentary  spina  bifida  of  the  sacrum  is  quite  common. 
Clavicle.  Occasionally  only  the  sternal  portion  of  the 
clavicle  is  present,  the  acromial  end  having  failed  to  form. 
Another  interesting  abnormality  which  has  been  occasionally 
observed  is  an  articulating  facet  upon  the  clavicle  forming  a 
joint  with  the  coracoid  process  of  the  scapula,  Fig.  313.   In 


ABNORMALITIES 


319 


Fig.  316. — Fourth    and    fifth    fingers 
arising  from  a  common  metacarpal. 


'*.  - 


\       5       ,      L  » 


Fig.  317. — Extra  digit  on  the  toe,  a  con- 
genital deformity. 


Fig.   3 1  S. —Congenital  absence  of 
the  fibula. 


320  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

the  writers'  series  of  cases  this  was  most  frequentl}^  found  in  the 
colored  race.  This  articulation  is  normally  present  in  birds. 

Scapula.  The  scapula  is  fairly  constant  in  structure,  but 
occasionally  what  is  known  as  congenital  elevation  is  seen. 
In  this  case  the  scapula  is  rotated  and  elevated.  The  etiology 
is  unknown,  but  is  probably  due  to  some  fetal  pressure. 

Shoulder.  iMost  of  the  deformities  of  this  joint  are  prob- 
ably secondary  to  birth  injuries;  dislocation  and  nongrowth  of 
the  humerus  are  also  probabi}'  secondary  to  such  injuries. 
The  lower  epiphysis  of  the  humerus  may  be  affected  in  a  similar 
manner. 

FoREARAL  Absence  or  partial  growth  of  either  bone  of  the 
forearm  (Fig.  314)  is  quite  common  and  occasionally  synostosis 
of  the  upper  third  of  the  forearm  is  seen. 

Hand.  Extra  digits  (Fig.  315),  fusion  of  the  phalangeal 
joints  (Fig.  316),  and  synostosis  of  the  metacarpals  are  the 
most  common  deformities  of  the  bones,  causing  club  hand. 

Femur.  Congenital  absence  of  this  bone  is  occasionally 
encountered.  Subluxation  of  the  head  is  sometimes  seen 
following  an  unrecognized  poliomyelitis  in  infancy.  The  patella 
may  be  either  absent  or  dislocated. 

Ankle  and  Foot.  Extra  digits  (Fig.  317),  fusion  of 
phalangeal  joints,  synostosis  of  the  metatarsus  and  club  foot 
are  the  most  common  abnormalities  in  this  region.  No  attempt 
is  made  to  enumerate  every  deformity,  only  the  more  common 
ones  that  are  occasionally  met  with  in  A-ray  examination. 

TiBL\  OR  Fibula.  Either  tibia  or  fibula  or  both  may  be 
absent  or  only  partially  present,  Fig.  318. 


CHAPTER!  XIV 
DYSTROPHIES 


CHAPTER  XIV 
Dystrophies 

OSTEITIS  deformans  was  first  described  by  Paget  and 
is  more  commonly  known  by  his  name.  It  seems  to 
be  a  chronic  inllammatory  process,  though  the  etio- 
logical factor  is  unknown,  and  it  occurs  ahnost  entirely  in  the 
third  age  period.  A  pathological  examination  shows  the  bone  to 
be  increased  in  size,  sometimes  in  length,  due  to  a  combination 
of  rarefying  and  proliferative  osteitis. 

The  weight-bearing  bones,  especially  the  pcKis,  lemur  and 
tibia,  are  most  frequently  involved;  the  spine  is  less  frequently 
affected.  The  skull  when  affected  is  the  most  typical  of  all. 

The  x-ray  changes  are  as  follows:  There  are  longitudinal 
striae  of  porosity  and  increased  density,  Figs.  319  and  320. 
This  is  due  to  rarefying  and  proliferative  osteitis.  There  is 
proliferation  of  periosteal  bone,  causing  the  bone  to  become 
wider.  When  the  rarefying  changes  are  most  predominant  the 
bones  are  weakened  and  bowing  and  fractures  ensue.  In  one 
case  under  obscr\ation  for  over  ten  years,  where  only  the 
tibia  was  involved,  the  bone  was  fractured  four  times  while 
walking  with  no  additional  trauma.  Union  took  place  very 
slowly,  about  fifteen  weeks  elapsing  each  time  before  there  was 
good  union.  During  the  entire  process  of  healing  theie  was 
but  little  callus  formation.  In  the  leg  the  overgrowth  of  the 
tibia,  with  fibula  unaffected,  generally  causes  a  marked  bowing. 

When  the  spine  is  affected  the  softening  of  the  body  of  the 
vertebra  with  the  arches  unaffected  causes  an  anterior  bowing. 

The  skull  changes  are  the  most  characteristic,  Fig.  321. 
The  plate  will  show  round,  knobbylike  masses  of  bone  lying 
between  the  inner  and  outer  tables  of  the  bone;  sometimes 
these  will  be  on  the  outer  table,  and  thus  the  head  will  have  a 
knobby  irregular  feeling  when  palpated.  The  best  description 

323 


324  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  319. — Osteitis  deformans. 


Fig.  320. — Osteitis  deformans  of  the  tibia. 
Note  the  marked  bowing  of  the 
tibia,  due  to  actual  overgrowth  of 
bone.  There  is  a  markedly  thick- 
ened cortex.  Striae  of  bone  absorp- 
tion and  bone  production  are  also 
present. 


DYSTROPHIES 


325 


of  this  condition  is  to  imagine  the  curled  kinky  hair  of  the  negro 
to  have  undergone  calcification. 

The  head  also  increases  in  size  l^ut  the  enlargement  is 
uniform  and  does  not  show  any  deformity  as  in  acromegaly. 
This  disease  is  more  common  in  the  male  than  in  the  female. 

Acromegaly.  This  lesion  is  never  seen  in  the  first  age 
period  and  but  rarefy  in  the  second.  The  third  age  period,  or  in 
middfe  and  ofd  age,   is  the  time  when  it  appears  or  is  recog- 


FiG.  321. — Clianges  seen  in  the  cranial  bones  in  osteitis  deformans. 


nized,  Fig.  122.  Disease  of  the  hypophysis,  cspeciaffy  in  derange- 
ment of  its  secretions,  seems  to  Idc  the  etiological  factor.  The 
roentgenogram  shows  a  general  overgrowth  of  the  cranial 
and,  in  fact,  all  the  bones.  The  increased  size  of  the  hands  and 
feet  is  especially  noticeable,  and  there  is  generafly  increased 
tufting  of  the  terminal  phalanges  giving  a  clubbed  finger 
effect,  Fig.  323.  The  changes  in  the  head  are  as  foflows:  There 
is  an  overgrowtli  of  the  frontal  l^onc,  gi\ing  what  might  be 


326  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  322. — Acromegalic  skull.   Note  the  overgrowth  of  bone,  prominent 
frontal  sinuses,  and  the  protruding  mandible. 


DYSTROPHIES 


32- 


termed  a  beeiled  brow  eflect;  the  frontal  sinuses  are  often 
markedly  enlarged,  and  the  mandible  will  be  lengthened  and 
will  protrude  so  that  there  will  be  no  ocehision  of  the  front 
teeth;  the  sella  turcica  is  frequently  much  enlarged  and  very 


Fig.  323. — Changes  in  the  bones  of  the  hand  in  acromegaly.  There  is 
increased  tufting  of  the  terminal  plialanges  and  increased  size  of  all  the 
bones  of  the  hand. 


deep,   suggesting   an   hypophyseal   tumor.    In   gigantism    the 
same  picture  will  frequently  be  seen. 

Osteomalacia.  This  disease  is  one  of  the  third  age 
period,  and  while  its  etiology  is  unknown  it  is  supposed  to  be  of 
an  inflammatory  nature.  It  is  characterized  by  an  absorption 
of  the  calcium  salts  in  an  irregular  manner;  the  bones  become 


328  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

softened  and  often  deformed.  It  is  much  more  common  in  the 
female  and  is  frequently  associated  with  pregnancy. 

The  x-ray  plate  will  show  the  bones  to  have  long  striated 
areas,  parallel  to  the  shaft,  of  diminished  density  due  to  ab- 
sorption of  the  lime  salts.  There  is  no  overgrowth  of  bone.  The 
long  weight-bearing  bones  are  bent,  and  while  there  are  no 
joint  changes  yet  the  altered  shape  of  the  bones  may  change 


Fig.  324. — Osteomalacia.  (Courtesy      Fig.  325. — Osteomalacia.  [Courtesy 
of  Dr.  G.  \V.  Holmes.)  ^  0/  Dr.  G.  W.  Holmes.) 

the  angle  of  the  weight-bearing  joint  surfaces,  which  circum- 
stance causes  secondary-  alterations.  Figs.  324  and  325. 

Fractures  are  frequent  on  account  of  the  absorption^of 
lime  salts,  and  they  unite  slowly  and  with  but  little  callus. 
The  condition  is  sometimes  mistaken  for  Paget's  disease. 
These  points  differentiate:  In  osteomalacia  more  bones  are 
involved,  the  skull  remains  unaffected,  and  there  is  no  new 
bone  formation;  in   Paget's  disease  the  bones  of  thejlower 


DYSTROPHIES 


329 


extremity  are  most  frequently  involved;  there  is  bone  proclue- 
tion,  and  there  are  typical  changes  in  the  cranial  bones. 

Chondrodystrophies.  This  disease  is  of  congenital  origin 
and  is  probably  due  to  some  interference  or  defect  in  the 
cartilaginous  structure,  especially  of  the  epiphyseal  cartilages. 
This  results  in  slow  growth  of  epiphyseal  bone,  and  sometimes 
complete  arrest  of  growth  in  certain  I:)ones.  The  periosteum   is 


Fig.  326. — Acliondroplasia. 

intact,  consequently  the  changes  noted  on  the  .v-ra\  phite  are 
limited  to  the  epiphyses.  The  bones  are  short,  ckie  to  poor 
epiphyseal  growth;  but  since  the  periosteum  is  intact  it  lays 
down  bone  in  the  normal  manner,  and  so  the  bones  are  of 
normal  width.  The  epiphyses  also  undergo  fusion  early 
resulting  in  abnormally  short  bones  of  normal  \\  idth.  At  the 
epiphysis  there  may  be  overgrowth  of  i^one,  which  gi\es  a 
broadened  end  to  the  bone.  The  ends  are  often  much  deformed 
from  aberrant  calcification.  Practicallx  all  the  bones  are 
involved,  and  there  is  more  or  less  deforniity.  Figs.  326  and  ^2~. 


330  INJURIES  AND  DISEASES  OF  B0NL3  AND  JOINTS 

In  cretinism  there  is  a  similar  change  in  the  bone.  In  fact, 
the  two  conditions  are  frecjuenti}'  associated. 

Pulmonary  Osteoarthropathy.  This  is  an  inliamma- 
tory  disease  associated  with  any  chronic  infection,  especially 
when  the  lungs  are  involved.   In  the  writers'  series  of  cases 


Fig.  327. — Achondroplasia  with  deformity  of  the  epiphysis  of  the  radius 
from  fauhj^  epiph^'seal  development. 


all  were  associated  with  pulmonary  tuberculosis  with  the 
exception  of  two,  one,  a  primary-  sarcoma  of  the  pleura,  the 
other  a  bronchiectasis.  The  periosteum  becomes  slightly 
raised,  and  there  is  a  deposition  of  calcium  salts  in  it,  but  not 
attached  to  the  bone,  Fig.  328. 

The  A-ray  plate  shows  a  generalized  periostitis  particu- 
larly of  the  metacarpals,  metatarsals,  and  the  phalanges  of  the 
hand  and  foot.  The  calcified  periosteum  is  raised,  with  a  clear 
space  between  it  and  the  bone,  but  there  is  no  change  in  the 


DYSTROPHIES 


331 


bone.  The  joints  frequently  show  swelhng  and  fluid,  but  the 
cartilage  is  intact.  The  flesh  shadows  of  the  hand  show  the  typ- 
ical ckibbed  fingers.  In  marl^ed  cases  practically  all  of  the  long 
bones  will  show  this  periosteal  change.  The  disease  is  one  of 
early  life  and  in  our  series  all  were  in  the  first  age  period. 


Fig.  328. —  Puhnonary   osteoarthropathy.    Note   the    periosteal    changes. 

iOsTEOGEXESis  IMPERFECTA.  This  is  a  childhood  infection 
and  is  apparently  congenital  in  origin.  All  the  bones  may  be 
invoKcd,  but  especially  those  of  the  lower  extrcniitx .  It  is 
characterized  by  absorption  of  the  linie  salts.  The  bones  on 
account  of  the  absence  of  lime  salts  become  so  atrophic  that  it 
is  often  dillicult  to  get  a  satisfactory  plate.  The  joints  are  never 
involved.  The  bones  become  soft  and   in  part  cartilaginous. 


332  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 


Fig.  329. — Osteogenesis    imperfecta   with  multiple   fractures.  The  bones 
of  the  lower  extremity  also  suggest  achondroplasia. 


DYSTROPHIES 


333 


In  such  cases  there  may  be  distortions  at  birth,  and,  on  account 
of  the  weakness  of  the  bones,  multiple  fractures  are  common, 
Figs.  329,  330  and  331. 

A  somewhat  similar  appearance  is  given  by  the  lesions  ol 
rickets  and  lues,  but  the  differential  point  is  that  in  the  latter 
disease  there  are  epiphyseal  changes,  while  in  the  foniur  the 
epiphyses  are  intact. 


Fig.  330. — Osteogenesis  imperfecta,     Fig.  331. — Osteogenesis  imperfecta, 
showing  multiple  fractures.  showing  multiple  Iractures. 

When  the  lesion  is  seen  after  the  child  has  walked  there 
will  be  deformities  due  to  softened  bone,  and  the  \ertebrae 
will  be  very  narrow  due  to  flattening  iroiii  j^rcssurc.  W  hen  the 
bones  are  fractured  they  unite  very  slowly  with  but  little 
callus  formation. 

DvsCHO.XDROPLASiA.  This  is  also  a  disease  of  the  car- 
tilaginous structures  in  utcro,  and  as  in  chondrodystrophia  the 


334  INJURIES  AND  DISEASES  OF  BONES  AND  JOINTS 

epiphyses  are  involved,  so  that  the  bones  are  shortened  and 
deformed.  But  there  is  one  feature  which  does  not  occur  in 
chondrodystrophia,  namely,  the  formation  of  multiple  exosto- 
ses arising  from  the  cortex. 

It  is  often  limited  to  one  side  of  the  body.  It  is  more  com- 
mon in  the  male  and  frequently  successive  generations  of  the 
same  family  will  show  this  involvement. 


INDEX 


INDEX 


Abnormalities  of  the  bones,   311 

ankle  and  foot,  320 

cervical  region,  312,  313 

clavicle,  318 

extra  ribs,  31 1 

femur,  320 

fibula,  320 

hand, 320 

lumbosacral  region,  314 

rudimentary  vertebra',  313 

scapula,  320 

shoulder,  320 

thoracic  region,  314 

tibia,  320 
Acetabulum,  fracture  through  the,  95,  96 

mechanical    alteration   of,    in    Perthes's 
disease,  202 

shape  of,  in  congenital  dislocaticjn,  135, 
137,  138 
Achondroplasia,  330,  332 
Acromegaly,  325 

cause,  325 

.v-ray  appearance,  325 
Acromial   process,    centers   of  ossification 

of.  35 
Acromion,  fractures  of,  62,  64 
Actinomycosis,  176 
Acute  polyarticular  rheumatism,  207 

x-ray  appearance  of,  208 
Acute  spondylitis  deformans,  302,  304 
Age,  as  factor  in,  bone  development,  27 
diagnosing  bone  tumors,  242,  251 
joint  lesions  of  children,  183 
production  of  fracture,  48 
.v-ray  diagnosis,  4 

laws  of  probability  regarding,  29" 

of  fracture,  estimate  of,  53 

relation  of,  to  fractures,  54 
Anatomy,  normal,  necessity  for  knowledge 

of,  4 
Aneurysms,  8 

of  the  thoracic  aorta  in  spine  in\'oIvc- 
ment,  307,  308 
22 


Angulation,  in  Colles's  fracture,  85 

in  fractures  of  the  spine,  296,  297 
Ankle,  abnormalities  of,  320 
Ankle  joint,  fractures  around,  117 

subluxation  of,  139 
Ankylosis,  as  repair  process  of  infectious 
arthritis,  212 

between  patella  and  femur,  gonorrheal 
origin  of,  216 

fibrous,  in  tuberculosis  of  the  joint,  197 

in  fracture  of  jihalanges,  90 

in  non-tuberculous  hij}  infections,  137 

in  spinal  conditions,  304 

in  typhoid  osteomyelitis  of  the  spine  ,175 
Arthritic  changes  due  to  old  age,  222 

in  ligaments  and  bursae,  233 

calcification    at    bony    attachments, 
233,  234,  235.  236,  23^ 
Arthritic  condition  present  in  eldcrl}'  indi- 
viduals, 70 
Arthritic  lesions  of  the  spine,  305 
Arthritis,  206 

indirect  evidence  of,  206,  207 

infectious,    Guldtliwaite's    classification 
of,  209 
resemblance  of  appearance  of  hemo- 
philia to,  233 

spinal,  223,  297 

See    also    Chronic     arthritis    and    Joint 
lesions. 
Arthritis  deformans,  206,  207 

atrophy  in,  207 

indirect  evidence  of,  207 
Astragalus,  centers  of  ossification  of,  41 

dislocation  of,  156 

fracture  of,  120 
Atelectatic  strip  of  lung  in  rickets,   188 
Atrophic  arthritis,  219 

conditions  present,  219 

.v-ray  appearance,  2i() 
Atrophy,  ditlcrentiation  of  local  and  gen- 


lormed  with  bone  splints,  i  2~,  128 


337 


338 


INDEX 


Atrophy,  in  arthritis  deformans,  207 
in  infectious  arthritis,  211 
in  non-union  of  fracture,  126 
in  rickets,  186 
of  age,  5 1 

of  quantity,  51,  138 
of  quality,  51 

presence  of  as  diagnostic  aid,   in  frac- 
tures, 49 
in  gout,  225 
usual  absence  of,  in  scurvy,  193 

Barton's  fracture,  86,  87 
"Baseball  finger,"  90 

Bence  Jones's  bodies  in  urine  as  diagnos- 
tic of  myeloma,  266 
Benign  tumors,  brief  outline  of  growth  of, 
255 
direction  of  growth  of,  248 
presence  of  bone  production  noted  in,  6 
Blood-vessels,  13,  15,  18 
Bone  cysts  as  related  to  fractures,  54 
Bone    destruction,    diagnosis    determined 
by,  5.  6 
causes  of,  5 
Bone  graft  in  non-union  of  fracture,  126 
Bone  infections,  see  Infections,  bone. 
Bone  involvement  as  factor  in  diagnosing 
bone  tumors,  253 
position  of,  as  diagnostic  point  in  bone 
tumors,  253 
Bone,  normal 

^ee  Normal  bone 
Bone   production,   absence   of,  in  Paget's 
disease,  328 
in  tuberculosis  of  the  joint,  197 
in  malignant  growths,  254 
as  a  diagnostic  point  in  fractures  of  the 

spine,  296,  297 
character  of,  as  diagnostic  point,  247 
causes  of,  5 

diagnosis  determined  by,  5,  6 
in  arthritis  of  the  spine,  297 
in  epiphsitis,  200 
in  mixed    tuberculous    joint    infection, 

214 
in  osteoma,  274 
in  osteosarcoma,  266 
in  Paget's  disease,  328 
in  periosteal  sarcoma,  263 


Bone  production  in  tuberculosis  of  joint 
if  sinus  formation  is  involved,  198 

origin  of  tumors  causing,  247 
Bone  tumors,  241 
Bones,  flat,  description  of,  21 

irregular,  description  of,  21 

long,  description  of,  20 
Brain  tumors,  282 

3c-ray  appearance  of,  due  to  internal  pres- 
sure, 283 
Brody's  abscess,  168 
Bronchiectasis  associated  with  pulmonary 

osteoarthropathy,  330 
Bursae,  arthritic  changes  in,  233 
Bursitis,  subdeltoid,  233,  234,  235,  237 

Callus,  formation  of,  in  fracture,  51,  52 

lack  of,  in  osteitis  deformans,  323 
Cancellous  bone,  15 

description  of,  15 
Capitellum,  fracture  of,  74 
Carcinoma,  8,  262 

bone  destruction  in,  5 

chief  characteristics  of,  255 

frequency  of,  in  age  periods,  253 

lack  of  bone  production  in,  247 

location  of  bone  involvement  in,  253 

non-union  of  fracture  in,  126 

of  the  spine,  302 

origin  of,  in  bone  tumors,  242,  246 
Caries  sicca,  214 

x-ray  appearance,  215 
gouged-out  areas,  215 
atrophy,  215 
Carpal  bones,   centers  of  ossification  of, 
34,  38 

dislocation  of,  151 
Cartilage,  17 

description,  17 
joint,  17 
costal,  18 

involvement    of,    in    dyschondroplasia, 

333 

in  chondrodystrophia,  329 
in  joint  injuries,  205 
resistance  of,  to  tumors,  241 
Centers  of  ossification,  23,  35 
Cervical  ribs,  extra,  neuritis  due  to  pres- 
sure of,  311 
Cervical  vertebra,  290 


INDEX 


339 


Charcot  joint,  225,  226,  227,  228,  229 
neuropathic  origin,  225 
x-ray  appearance,  225-230,  302 
periostitis,  231 
atrophy,  absence  of,  23  [ 
similarity  of  gout  to,  225 
Charcot  spine,  302,  304,  305 

x-ray  appearance,  302 
Chauffeur's  fracture,  49 
Chondrodystrophy,  329 
effect  of,  on  epiphyses,  43 
cause,  329 

x-ray  appearance,  329 
Chronic  arthritis,  209 
infectious  arthritis,  209 

diversified  x-ray  appearance  of,  209 
first  stage,  21 1 
second  stage,  21 1 
atrophy,  2 1 1 

narrowed  joint  space,  21 1 
third  stage,  21 1 

replacement    of  destroyed    area, 
21 1 
tuberculosis,  213 

x-ray  appearance,  213 
caries  sicca,  214 
gonorrheal,  21  5 
luetic,  217 
atrophic,  219 

conditions  present,  219 
x-ray  appearance,  219 
hypertrophic  arthritis,  220 
x-ray  appearance,  221 
Clavicle,  absence  of  acromial  end  of,  318 
centers  of  ossification  of,  35 
metastasis  of,  from  prostate,  260 
spurious  facet  attached  to,  318 
Club  foot,  x-ray  of,  139 
Club  hand,  due  to  synostosis  of  the  meta- 
carpals, 320 
x-ray  of,  139 
Clubbed    fingers,    in    pulmonary    osteoar- 
thropathy, 331 
Coccidoidal  granuloma,  177 
Cod-liver  oil  treatment  in  rickets,  meta- 
bolic changes  from,  195 
Colles's  fracture,  50,  79,  84,  87 
angulation  in,  85 
dislocation  in,  85 
impaction  in,  85 


Colles's  fracture,  relation  of  age  to,  48 
Condyle,   fractures  through,   59,   79,    109, 

1 12 
Congenital  abnormalities  due  to  injury  of 

cartilage,  25 
Congenital  dislocations,  i  33 
Connective  tissue  origin  of  sarcoma,  246 
Coracoid,  fractures  of,  62,  148 
Coracoid  process,  centers  of  ossification  of, 

35 
Coronoid  fossa,  fracture  of,  75 
Coronoid  process,  fracture  of,  59,  60,  76 
Cortex,  13,  14 
description,  14 
as  point  of  origin  in  bone  tumors,  243, 

245.  247 
infection  of,  known  as  osteitis,  159 
nature  of  expansion  of,  in  bone  tumors, 

247 
Costal  cartilage,  18 

Coxa  vara,  intertrochanteric  fracture  with, 
106,  108 
presence  of,  in  Perthes's  disease,  202 
Cranial  bones,  changes  in,  in  Paget's  dis- 
ease, 329 
Cretinism,   association  of,   with  chondro- 
dystrophies, 330 
effect  of,  on  epiphyses,  42 
Cuboid,  centers  of  ossification  of,  41 

fracture  of,  123,  124 
Cuneiform,  38 

external  and  internal,  centers  of  ossifi- 
cation of,  41 
fracture  of,  123 
Cyst,  271 
origin,  271 

differentiation  from  cnchondroma,  2~2 
example  of  growth  of,  248 
Cysts,    action    of,    in    expanding   cortex, 
167 
bone,  origin  of,  246 

lack  of  bone  production  In,  unless  ac- 
companied by  fracture,  247 
relation  of,  to  fracture  of  mandible,  59 

Dakin  tubes  in  compound  fracture,  107 
Deformity,  lateral,  as  diagnostic  point  In 

fractures  of  the  spine,  296,  297 
Density,  increased,  in  osteitis  deformans, 

323 


340 


INDEX 


Diagnosis,  differential,  6 

direct  evidences  for,  bone  destruction,  6 

bone  production,  6 

pressure  effects,  6 

extension  of  lesion,  6 

atrophy,  6,  7 

absence  of  pain,  7 
indirect  evidence  for,  age,  8 

sex,  8 
in  bone  tumors,  241,  284 
in  dyschondroplasia,  334 
in  osteomalacia,  328 
in  osteomyelitis,  170 
in  rachitic  joint  infection,  188 
in  scur\y,  194 
See  also   under  specific  injuries  and 

diseases. 
Diagnosis,  x-ray,  elements  involved  in,  3,  4 
See    also     under    specific    injuries  and 

diseases. 
Diaphyseal  side  of  epiphyseal  line  involved 

in  lues,  189 
Digits,  extra,  in  the  toe,  319,  320 
Dislocation,  from  hip  injury,  8 
in  Colles's  fracture,  87 
of  the  spine,  304,  305 
Dislocations,  acquired,  145 

shoulder,  145 

elbow,  146,  149,  150 

ulna  and  radius,  148,  149 

wrist,  151 

hand,  151 

pelvic  bones,  151 

hip,  154 

patella,  155 

knee,  155 

fibula,  156 

foot,  156 
congenital,  133 

hip,  133 

.V- ray  differentiation,  134,  136,  137 
frequency,  137 

shoulder  joint,  141 

epiphyses,  141 
posterior,  in  Colles's  fractures,  85 
relation  of,  to  age,  48 
Displacement,  in  subperiosteal  fracture,  79 
necessity  of  reporting,  54 
of  ulna,  76 
Dyschondroplasia,  333 


Dystrophies,  323 

osteitis  deformans,  323 
acromegaly,  325 
osteomalacia,  327 
chondrodystrophies,  329 
pulmonary  osteoarthropathy,  330 
osteogenesis  imperfecta,  331 
dyschondroplasia,  333 

Enchondroma,  269 

fracture  an  accompanying  feature,  271 

nature  of  growth,  271 

differentiation  from  cyst,  272 

origin  of,  246 
Elbow,  fracture  of,  76,  77,  146 
Endarteritis  obliterans  involved  in  Ray- 
naud's disease,  177 
Epicondyles,  fracture  of,  73 
Epiphyseal  cartilages,  defect  of,  as  cause 

of  chondrodystrophies,  329 
Epiphyseal  centers  of  the  vertebrae,  289, 

290 
Epiphyseal  changes  in  osteogenesis  imper- 
fecta, 333 
Epiphyseal  flattening  in  Perthes's  disease, 

202 
Epiphyseal  line,  changes  in,  in  scurvy,  191 

erroneous  diagnosis  of,  4 

expanded  in  rickets,  184 

fractures  along,  of  femur,  99 

.v-ray  appearance  of,  24 
Epiphyseal  separation,  erroneous  diagnosis 
of  as  dislocation,  146 

in  hip  injun*%  8 

in  metacarpals,  88 

likelihood  of,  48 

of  pelvis  in  crushing  injuries,  95 

of  radius  as  erroneously-  diagnosed,  dis- 
location, 1 5 1 
Epiphyses,  13,  23,  33 

abnormalities  of,  42,  141 

value  in  estimating  age,  33 

appearance  of  centers  of  ossification, 

33 

variation  due  to  malnutrition,  34,  35 
scapula,  35 
clavicle,  35 
humerus,  36 
radius,  38 

fracture  of,  81 


INDEX 


341 


Epiphyses,    carpa!    and    metacarpals,    34, 

38,41 
phalanges,  38,  41 
pubis  and  ischium,  39 
lemur,  39 

displaced  in  fracture,  109 
patella,  40,  42 
tibia,  40,  42 

tuberculosis  in,  171 
fibula,  40 
OS  calcis,  41 
astragalus,  41 
cuboid,  41 
cuneiform,  41 
scaphoid,  41 
vertebrae,  41,  43 
Epiphysitis,  acute,  134,  136 
in  joints  of  children,  183,  199 
x-ray  appearance,  199 
sharp  outlines,  199 
focal  spots  of  disease,  199 
ankylosis,  bony,  200 
bone  production,  presence  of,  200 
summary  of  diagnostic  points,  200 
Etiology    in    Perthes's   disease,    unknown 

character  of,  202 
Exostoses,  275 

in  arthritis  of  the  spine,  297 

in  early  stages  of  gout,  225 

in  spinal  lesions,  304 

multiple,  in  dyschondroplasia,  334 

of  OS  calcis,  233,  237 

gonorrheal    and    non-gonorrheal    types, 

23<),  237 
presence  of,  in  infectious  artliritis,  211 

Facial  bones,  fracture  of,  57 
Femur,  abnormalities  of,  320 
centers  of  ossification  of,  39 
fracture  of,  93,  96,  99 

neck  of,  legal  case  relating  to,  53 
neck  of,  prevalent  in  old  age,  48 
involvement  of,  in  osteoma,  274 

in  osteitis  deformans,  323 
metastasis  of,  from  prostate,  260 
non-union  in  fracture  of,  127 
site  for  giant-cell  sarcoma,  269 
site   lor  ossif\  ing   hematoma    in   adults, 
278 
Fibroma,  275 


Fibroma,  similarity  in  appearance  to  cyst 

or  enchondroma,  276 
Fibula,  abn<jrmalities  of,  320 

benign  tumor  in,  249 

centers  of  ossification,  41 

dislocation  of,  i  56 

fracture  of,  113 

x-ray    appearance   of  Charcot    joint   in, 
230 
Fluid    formation    in    acute    polyarticular 

rheumatism,  207 
Foot,  abnormalities  of,  320 

dislocation  of,  156 
Forearm,  abnormalities  of,  320 

fracture  of,  75 
Fracture,  Barton's,  86,  87 

Colles's,  84,  85 

definition  of,  47 

erroneous  diagnosis  of,  3,  313,  314 

from  hip  injury,  8 

of  neck  of  femur,  legal  case  relating  to, 

53 

of  styloid  of  the  radius,  87 
prcvalency  of,  in  old  age,  48 
multiple,   in  enchondroma,  270 
Fractures,   kinds  of,  47 
elements  affecting,  47 

muscular  tension,  47 

age  and  sex,  48 

occupation,  48 
study  of  roentgenogram,  49 

condition  of  soft  tissues,  49 

bone   atrophy,  49 

formation  of  callus,  ii,  52 

fractures     from     pathological    causes, 

53 
of  the   upper  extremities,  classified  ac- 
cording to  age,  54 
skull,  54 
facial  bones,  5" 
mandible,  57,  ,8,  5(>,  60 
clavicle,  59 

scapula,  62,  63,  6';,  66 
humerus,  64,  67,  68,  71 
forearm,  74 
wrist,  87 
hand,  88 
ribs,  91 
sternum,  94 
jjelvis,  94 


342 


INDEX 


Fractures,  of  the  lower  extremities  classified 
according  to  age,  99 
femur,  99 
patella,  109 
tibia,  113 
fibula,  1 1 3 

bones  of  the  foot,  1 20 
non-union,  127 
bone  splints,  128 
in  osteitis  deformans,  323 
in  osteomalacia,  328 
multiple,  in  osteogenesis  imperfecta,  333 
of  the  spine,  291 
Frontal  bone,  overgrowth  of,  in  acromeg- 
aly, 325 
Functional  conditions  of  the  spine,  306 

Gastrocnemius  muscle,  displacement  due 

to,  109 
Gigantism,   resemblance  of  x-ray  appear- 
.    ance  of,  to  acromegaly,  327 
Glenoid  fossa,  fractures  of,  62 
Goldthwaite,  classification  of,  for  arthritic 

conditions,  209 
Gonorrheal  arthritis,  215 

ankylosis  between  patella  and  femur  as 
diagnostic  of,  216 
Gout,  225 

.v-ray  appearance,  225 
swelling,  225 
atrophy,  225 

punched-out  areas,  225,  226 
exostosis  in  early  stages,  225 
Green-stick  fracture,  16,  70,  72,  79,  80 
of  clavicle,  61 
of  femur,  108 
Grafting  of  bone  in  fracture,  126 
Growth  of  tumors,  brief  outline  of,  253 
Growths,  spread  of  infection  in,  6 

Hand,  abnormalities  of  the  bones  of,  320 

bones  of,  involved  in  enchondroma,  271 

fractures  of  the,  88 
Haversian  canals,  6,  160,  165,  254 

in  cortex,  14 
Head,  fractures  of,  54 
Hemangiomata,  276  ! 

presence  of  calcified  bodies  in,  277 
Hematomata,  246 

in  scurvy,  193 


Hematomata,  ossifying,  277 

inflammatory  in  origin,  277 
connection   with  scurvy  in   children, 

278 
association    with    severe    trauma    in 

adults,  278 
difi"erentiation,  278,  280 
Hemophilia,  233 

clinical  appearance  simulates  infectious 

arthritis,  233 
AT-ray  appearance,  233 

gouged-out  areas,  232,  233 
hazy,  233 

organised  blood  clots,  233 
Hemorrhage,  13 
in  scurvy,  191,  194 

subperiosteal,  absence  of,  in  rickets,  188 
Hereditary  character  of  dystroplasia,  334 
Hip,  dislocation  of,  133,  152,  153,  154 
fracture  of,  diagnosis  of,  in  different 
age  periods,  8 
Hip  joint  involved  in  Perthes's  disease,  201 
Histology,  knowledge  of,  as  aid  to  x-ray 

diagnosis,  4,  5 
Howland,  195 

Humerus,  centers  of  ossification  of,  36 
fractures  of,  64 

injuries  of,  as  cause  of  dislocations,  141 
involvement  of,  in  bone  cyst,  272 

in  osteoma,  274 
metastasis  of,  from  hypernephroma,  262 
Hypernephroma,  260 

origin,  260 
Hypertrophic  arthritis,  8,  220 
x-ray  appearance,  221 

atrophy,  presence  of,  221 
bony  exostoses,  222 
new  bone  formation,  222 
mechanical  ankylosis,  222 
in  spinal  lesions,  298,  304 
Hypophyseal  tumors,  expansion  of  sella 

turcica  in,  283 
Hypophysis,   irregularity  in  secretion  of, 
as  cause  of  acromegaly,  325 

Iliac  crests  roughened  by  calcification  in 

arthritis,  233 
Ilium,  fracture  of,  93,  95 
Impaction,  in  Colles's  fracture,  85,  86,  87 

in  fracture  of  femur,  102 


INDEX 


343 


Infantilism,  effect  of,  on  epiphyses,  42 
Infection,    presence    of   bone    production 
noted  in,  6 
relation  of,  to  fracture  of  mandible,  59 
spread  of,  through  medullary  canal,  17 
stages  of,  in  joint  lesions,  205 
Infections,  bone,  159 
osteomyelitis,  159 

channels  of  infection,  159 

AT-ray     appearance     during     various 

periods,  164-167 
acute,  167 
chronic,  167 
diagnostic  points,  170 
tuberculous,  170 
luetic,  172 
typhoid,  175 
actinomycosis,  176 
Raynaud's  disease,  176 
leprosy,  177 

coccidoidal  granuloma,  177 
mineral  poisoning,  180 
special  infections,  180 
virulent,  bone  destruction  in,  5 
Infectious  arthritis  in  the  spine,  298 
tuberculous,  298 
non-tuberculous,  299 
See    also   Chronic   arthritis    and   Joint 
lesions. 
Inflammatory    nature    of    osteitis    defor- 
mans, 323 
Intervertebral   space,   involvement  of,   in 

fractures  of  the  spine,  297 
Invasion,    as    diagnostic    point    in    bone 
tumors,  251,  252 
change  of  aspect  of,  in  brain  tumors,  284 
lack  of,  in  osteoma,  272 
Involucrum,  diagnostic  value  of,  in  osteo- 
myelitis, 174,  17$ 
Ischium,  centers  of  ossification  of,  3() 
fracture  of,  93,  95 

Joint  cartilage,  17 

susceptibility  of,  to  infection,  241 
Joint  infection  of  osteomyelitis,  159 
Joint,  21 

constituents,  21 

synovial  membrane,  21 

invisibility  to  .v-ray,  21 

indirect  evidence  of  pathology,  21 


Joint  lesions,  24,  25 
in  adults,  205 
parts  involved  205 
.v-ray  appearance,  factors  governing, 

205 
stages  of  infection,  205 
arthritis,  differentiation  of,  206 

acute  polyarticular  rheum'atism,  207 

infectious,  209 

chronic  arthritis,  209 

summary  of  differential  points,  222 

changes  due  to  old  age,  222 

in  the  spine,  223 

villous,  223 
non-arthritic,  224 

gout,  225 

Charcot  joint,  225 

syringomyelia,  232 

hemophilia,  233 
arthritic  changes  in  ligaments,  233 
in  children,  183 

relation  of  age  to,  183 
rickets,  183 
congenital  lues,  188 
scurvy,  191 
tuberculosis,  195 

epiphysitis  (non-tuberculous),  199 
Pcrthes's  disease  or  juvenile  deform- 
ing osteochondritis,  201 
Joint  mice  in  hypertrophic  arthritis,  222 
Joint  space,  narrowed,  in  infectious  artii- 
ritis,  21 1 
in  tuberculosis,  196,  214 

Knee,  dislocations  of,  155 
Kyphosis,  tuberculous,  299 

Laminae  of  the  spine,  non-union  of,  313 

Lane  plates,  use  of,  in  fractures,  129 

Lateral   deformity   as  a   diagnostic   point 
in  fractures  of  the  spine,  296,  297 

Legg  of  Boston,  20 1 

Leprosy,  177' 

Ligaments,  arthritic  changes  in,  233 
imbedded  in  cartilage,  17 

Lues,  172 

lace  work  type  of  periostitis,  173 
as  joint  infection  in  childrn,   183 
congenital,  in  relation  to  joint  lesions  in 
children,   iSS 


344 


INDEX 


Lues,  congenital,  .v-ray  appearance,  i88 
multiple  involvement,  i88 
changes  in  the  epiphyseal  line,  189 
presence  of  punched-out  areas,  190 
atrophy,  usual  absence  of,  190 
periostitis,  190 
summan.-  of  diagnostic  points,   190 
effect  of,  on  epiphysis,  42 
similarity-  of,  to  osteogenesis  imperlecta, 

333 

to  osteomyelitis,  i~i 
Luetic  arthritis,  2i~ 

conditions  present,  2 1  - 

.v-ray  appearance,  21- 
Lumbar  vertebrae,  abnormalities  of,  314 
Lumbosacral  region,  abnormalities  in,  314 
Lymph  vessels,  13,  18 
Lymphoid  origin  of  osteomyelitis,  159 

Malar  bone,  fracture  of.  57 

Malignancy    of  tumors    dependent    upon 

invasion,  251 
Malignant  tumors,  bone  destruction  in,  5 

character  of  growth  of,  248,  253 
-NLindible,  fracture  of,  j~,  58,  59,  60 

involvement  of,  in  typhoid  osteomyeli- 
tis, 175 

lengthening  of,  in  acromegaly,  327 
Manubrium,  fracture  of,  94 
Marie-Striimpel  type  of  spondylitis,  223, 

299,  304 
Medullars- artery,  15 
Medullar\-  canal,  16 

as  point  of  origin  in  bone  tumors,  243, 
244 

as  road  for  osteomyelitic  infection,  165 
Medullary-  infection,   kno\^n   as  myelitis, 

159 
Metabolic    changes    in    rickets    resulting 

from  cod-liver  oil  feeding,  195 
Metabolism,  faulty,  as  cause  of  non-union 

in  fracture,  127 
Metacarpal,  periostitis  of,  in  pulmonary 
osteoarthropathy,  330 

thumb,  a  vestigial  phalanx,  43 

tuberculosis  in,  i~2 
Metacarpal  bones,  centers  of  ossification 
of,  38,  41 

dislocation  of,  151 

fractures  of,  88 


Metastasizing  to  bone,  absence  of,  in  brain 
tumors,  283 

Metastatic  infection  through  the  medul- 
lary^ canal,  17 

Metatarsals,  dislocation  of,  156 
fracture  of,  124,  125 

periostitis  of,  in  pulmonarv'  osteoarthro- 
pathy, 330 

Metatarsus,  synostosis  of  the,  320 

Mineral  poisoning  as  cause  of  bone  infec- 
tion, 180 

Muscular  tension,  47 

Myelitis,  definition  of,  159 

Myeloma,  266 

diagnostic  points,  266,  267 

Myositis  ossificans,  differentiation  of,  from 
ossifying  hematoma,  280 

Myxoma,  276 

Nasal  bone,  fracture  of,  57 

Necrosis,  evidence  of,  in  fracture,  126 

Negro  race,  presence  of  articulating  facet 

on  the  clavicle  in,  320 
Neuritis  due  to  pressure   from  extra  cer- 
vical ribs,  31 1 
Neuropathic  conditions  of  the  spine,  304 
Neuropathic  origin  of  Charcot  joint,  225 
Non-tuberculous  arthritis  of  the  spine,  299 
Non-tuberculous  joint  infections  in  chil- 
dren, 183 
Non-union,  congenital,  in  the  lumbosacral 
region,  316 
frequency  of,  in  fracture  of  the  femur, 

102 
of  fractures,  126 
causes,  126,  127 

bone  splints,  127,  128 
of  laminae  of  the  spine,  313 
Normal  bone,  13 
constituents,  13 
periosteum,  13 
cortex,  14 

medullary  canal,  16 
nutrient  foramen,  16 
cartilage,  17 
classification,  18 
long  bones,  20 
flat  bones,  2 1 
irregular  bones,  21 
joints,  21 


INDEX 


345 


Normal  bone,  growth,  22 

function  of  cpiph\  scs,  23 

centers  of  (ossification,  23 

epiphyseal  line,  24 

joint  lesions  in  children,  24 

developmental   variations   in   various 

age  periods,  26,  27 
variations  due  to  sex,  27,  28,  29 
Nutrient   canal,    importance   of",  in  meta- 
static malignancy,  241 
Nutrient  foramen,  16 
description,  16 
entrance  for  infections,  17 

Occupation,  as  factor  in  shoulder  disltjca- 
tion  of  males,  145 
relation  of,  to  fracture,  49 
Olecranon,  centers  of  ossification  of,  37,  38 
fracture  of,  75 

associated    with    dislocation    of    the 
elbow,  148 
Os  calcis,  centers  of  ossification  of,  41 

fracture  of,  123 
Os  magnum,  38 
Osteitis,  definition  of,  150 
Osteitis  deformans,  as  related  to  fractures, 

54 

occurrence,  323 

x-ray  changes,  323 
Osteitis  fibrosa  cystica,  280 

probable  inflammatory  origin,  280 

softening  of  bones  and  elongation,  280 

A'-ray  appearance,  281 
expansion  of  cortex,  282 
cystlike  areas,  282 

differential  diagnosis  of,  282 
Osteoarthropathy,  pulmonary,  330 

inflammatory  character,  330 

.v-ray  appearance,  330 
Osteochondromata,  action  of,  in  e\|:)and- 

ing  cortex,  167 
Osteogenesis  imperfecta,  186,  331 

atrophic  condition  of  bones  in,  331 
Osteoma,  272,  273 

bone  production  as  indicati\e  of,  6 

origin,  2^6,  272 

.v-ray  appearance,  2-4 

multiple  character  of,  274 

in  the  spine,  303 
Osteomalacia,  327 


Osteomalacia,  as  related  to  fractures,  54 

inflammatory  character  of,  327 

.v-ray  appearance  of,  328 

differential  diagnosis  of,  328 
Osteomyelitis,  acute,   127,  167 

association  of  mandible  fracture  with,  59 

as  related  to  fracture,  54 

as  sequela  in  fractured  phalanges,  90 

channels  of  infection  of,  159 

chronic,  167 

difTerentiation  between,  and  malignant 
tumors,  254 

erroneous      diagnosis     of,     for     osteitis 
fibrosa  cystica,  282 

tuberculous,  170 

luetic,  172 

spread  of  infection  in,  5 

.v-ray   appearance   during  various  peri- 
ods, 164-167 
Osteosarcoma,  263 

origin,  246,  263 

bone  production  in,  6,  26.\. 

destruction  of  the  shaft,  264 

differentiation    of,    from    ossifying 
hematoma,  279,  280 

in  the  spine,  303 
Os  trigonum,  presence  of,  in  fracture  of 

the  ankle,  122 
Ovaries  and  uterus,  carcinoma  of,  258 

Paget,  31 1 

Paget's  disease,  erroneous  diagnosis  of,  for 

osteomalacia,  328 
Pain,  absence  of,  in  Charcot  joint,  231 
Painful  heels,  exostoses  (if  os  calcis  or,  233, 
234,  237 

gonorrheal    and    non-gonorrheal    types, 

236 
Park,   195 
Patella,  abnormalities  of,  320 

center  of  ossification  of,  40,  42 

fracture  of,  109,  155 
Pathological  causes  of  fractures,  53 
Pathology,  value  of,  in  .v-ray  diagnosis,  3, 

4.  243 
Pelvic  bones,  dislocation  of,  i  ■;  i 

metastasis  of,  from  prostate,  260 
Pelvis,  fracture  of,  94 

involved  in  osteitis  deformans,  323 

of  female  compared  with  the  male,  29,  30 


346 


INDEX 


Pelvis,  shape  of,  influenced  by  walking,  134 

in  hip  dislocation,  135 
Periosteal  infection,  known  as  periostitis, 
159 
of  osteomyelitis,  159 
Periosteal  sarcoma,  263 

bone  production  in  soft  tissues.  263 
bone  striae  perpendicular  to  shaft,  diag- 
nostic point  of,  263 
origin  of,  246 
Periosteum,  13 
description,  13 
function,  13 
.v-ray  appearance,  14 
as  point  of  origin  in  bone  tumors,  243 
effect  of  tearing  of,  on  callus  formation, 
52 
Periostitis,  definition  of,  159 
in  rickets,  184 
mistakes  in  diagnosis  of,  4 
of  metacarpals,   metatarsals   and   pha- 
langes    in     pulmonan.'     osteoarthro- 
pathy, 330 
presence  of,  in  scurvy  of  the  joints,  193 
Perthes,  201 

Perthes's  disease,  183,  200,  201 
description  of,  201 
x-raj"  appearance  of,  202 
clear  bone  detail,  202 
epiphyseal  flattening,  202 
mechanical   changes   in   acetabulum, 
202 
etiological  factor  in,  202 
Phalangeal    enlargement    in    acromegaly, 

325 

Phalangeal  joints,  fusion  of,  320 
Phalanges,  dislocations  of,  151 

fractures  of,  90,  125 

involvement   of,  in  Raynaud's  disease, 
176 

of  the  feet,  dislocation  of,  156 

periostitis  of,  in  pulmonary  osteoarthro- 
pathy, 330 
Phalanx,  presence  of  fibroma  in,  2~6 
"Pigeon  breast"  of  rickets,  i8~ 
Pisiform,  38 
Poliomyehtis,  abnormal  hip  due  to,  140 

as  cause  of  subluxation  of  the  head  of 
the  femur,  320 
Porosity  in  osteitis  deformans,  323 


Pott's  fracture,  119,  120 

associated  with  dislocation,  156 
Pressure  destruction,   as  cause   of  spinal 

lesions,  307,  308 
Pressure  effects,  and  extension  of  lesion  in 

differential  diagnosis,  6 
Proliferation  of  periosteal  bones  m  osteitis 

deformans,  323 
Pronator  muscles,  prevention  of  reduction 

of  ulnar  fracture  because  of,  82 
Prostate,  carcinoma  of,  258 
Pubis,  centers  of  ossification  of,  39 

fracture  of,  93,  95 
Pulmonars'  osteoarthropathy,  330 
Pulmonary    tuberculosis,    association    of, 

with  osteoarthropathy,  330 

Quadriceps  attachment  to  patella,  calcifi- 
cation of,  233 

Radius,  centers  of  ossification  of,  37,  38 
chaiiff^eur's  fracture  of,  49 
dislocation  of,  148 
fracture  of,  75,  77,  78,  84,  87,  148 
Raynaud's  disease,  176 
Ribs,  abnormalities  of  the,  311 

fracture  of,  91 
Rickets,  8 

as  joint  infection  in  children,  183 
.v-ray  appearance,  184 
atrophy,  186 
chest  appearance,  186 
multiple  involvement,  184 
periostitis,  usual  absence  of,  184 
saucer-shaped  expansion  of  epiphy- 
seal line,  185,  188 
summary-  of  diagnostic  points,  188 
effect  of,  on  epiphyses,  42 
metabolic  changes  caused  by  cod-liver 

oil  feeding  in,  195 
similarity  of,  to  osteogenesis  imperfecta, 

333 

Roentgenogram,  definition  of,  3 

See  under  specific  injuries  and  diseases 
for  x-ray  appearance. 
Rudimentary  vertebrae,  313 

"Saber  chin"  in  rickets,  188 

Sacral  vertebrae,  abnormalities  of,  314 


INDEX 


Sacralization  of  the  fifth  lumbar  vertebra, 

42,  318 
Sacroiliac  subluxation,  307 

non-existence  of,  151 
Sacrum,  metastasis  of,  from  prostate,  260 
Sarcoma,  8 

absence  of  bone  production  in,  247 
associated  with  osteoarthropathy,  330 
bone  destruction  in,  5 
confusion  of  ossifying  hematoma  with, 

280 
connective  tissue  origin  of,  246 
erroneous  diagnosis  of,  for  fracture,  61 
for  hematoma  in  scurvj',  193 
for  osteitis  fibrosa  cystica,  282 
example  of  destroyed  cortex  in,  250 
frequency  of,  in  age  periods,  253 
giant-cell,  267,  303 

benign  character  of,  250 
nature  of  growth,  267,  268 
origin,  268 
hypothetical     exclusion     of,     in     bone 

tumors,  243 
non-union  of  fracture  in,  126 
round-cell,  262 
origin,  262 

similarity     in    .v-ray     appearance    to 
carcinoma,  262 
spindle-ccil,  263 

-v-ray  appearance,  263 
Scaphoid,  38 

fracture  of,  87,  88,  123 
Scapula,  abnormalities  of,  320 
centers  of  ossification  of,  35,  41 
fractures  of,  62,  63 
metastasis  of,  from  prostate,  260 
Scoliosis,  42,  306 
causes,  306 
curves  in,  294,  295 
due  to  rudimentary  vertebra,  314 
Scurvy, 8 

as  joint  infection  in  children,  183 
connection  of,  with  ossifying  hematoma, 

278 
effect  of,  on  epiphyses,  42 
joint  involvement  in,  191 
.v-ray  appearance,  191 
multiple  lesions,  191 
changes  in  epiphyseal  line,  191 
Triinimer  zone,  192 


Scurv}-,    joint    involvement    in,    atrophy, 
usual  absence  of,  193 
periostitis,  presence  of,  193 
hemorrhage,  192,  193,  194 
summary  of  diagnostic  points  in,    194 
Sella  turcica,  enlargement  of,    in  acrome- 
galy. 327 
expansion   of,    in    hvpophyseal    tumors, 
283 
Semilunar,  38 

dislocation  of,  151,  155 
fracture  of,  88 
Sequestrum,  presence  of,  in  osteomyelitis, 

162,  164,  165,  172,  175 
Sesamoids,  fracture  of,  125 
Sex,  as  factor,  in  diagnosing  bone  tumors, 
242.  253 
in  bone  development,  27 
in  incidence  of  fracture,  48,  49 
relation  of,  to  acromegaly,  325 
to  dyschondroplasia,  324 
to  osteomalacia,  328 
Shoulder,  abnormalities  of,  320 
Shoulder  joint,  dislocation  of,  141 
Sinus  formation  in  tuberculosis  of  joint, 

result  of,  198 
Sinuses,  frontal,  enlargement  of,  in  acro- 
megaly, 327 
in   tuberculous   joints   producing  infec- 
tion, 214 
Skull,  fractures  of,  54 
displaced,  $^ 
linear,  55 

of  the  base,  $y 
of  the  vertex,  56 
involvement  of,   in  osteitis  deformans, 

323 
lack  of  involvement  of,  in  osteomalacia, 
328 
Skull  changes  in  osteitis  deformans,  323, 

325 
Soft  tissues,  condition  of,  in  cases  of  frac- 
ture, 219 
shadows  in,  diagnostic  value  of,  1 19 
Spina  bifida,  314,  318 
Spine,  abnormalities  of,  42 
arthritis  in,  223 
conformation  of,  289 
peculiarities  of  specific  divisions,   289 
cervical,  290 


348 


INDEX 


Spine,   peculiarities   of  specific   divisions, 
thoracic,  290 
lumbar,  290 

fifth,  291 
classification  of  lesions,  291 
fractures,  291 

diagnostic  points,  296 
arthritis,  297 

.v-ray  changes,  297 
infectious  arthritis,  298 
acute  spondylitis  deformans,  302 
Charcot  spine,  302 
syringomyelia,  302 
tumors,  302 
application  of  classification   aids,  303, 

304 
functional  conditions,  306 
scoliosis,  307 

sacroiliac  subluxation,  30" 
ligamentous  changes,  30" 
pressure  destruction,  30",  308 
involvement  of,   in  osteitis  deformans 

323 

in  typhoid,  i~5 

of  the  scapula,  fractures  of,  62 
Spinous  processes,  fractures  of,  292 
Spondylitis,  Marie-Strumpel  type  of,  223 
Spondylitis  deformans,  299 

.v-ray  appearance,  302 

acute,  223,  302 
Sprain,  fracture  diagnosed  as,  ii~ 
Sprains  and  dislocations,   relation  of,   to 
age,  48 

ligamentous,  mistaken  for  subluxations, 
152 
Sternum,  fracture  of,  92,  94 
Styloid,  of  the  radius,  fracture  of,  87 

of  ulna,  fracture  of,  81 
Subcoracoid  fracture  of  shoulder,  145 
Subdeltoid  bursa,  calcification  at,   in  ar- 
thritis, 233,  234,  235,  23- 
Subdeltoid  bursitis  confused  with  fracture 

of  tuberosity  of  humerus,  69 
Subglenoid  fracture  of  shoulder,  145 
Subluxation,    of  the    head    of  the  femur, 
320 

in  the  sacroiliac  region,  307 
Subperiosteal  fracture,  79 

absence  of  callus  and  displacement  in,  52 
Superior  maxilla,  fracture  of,  57 


Supracondyloid  fracture,  72,  73 

erroneously    diagnosed    as    dislocation, 

146 
of  humerus,  deposit  of  callus  in,  53 
Surgical  interference,  in  fracture,  129 
necessity    for    knowledge    of,    in    bone 

tumors,  284 
necessity  for  recognition  of,  180 
Symphysis,  fracture  of,  96 
Symphysis  pubis,  separation  of,  in  females, 
8  ' 
in  males,  8 
Synostosis,  of  rib  bodies,  314 

of  the  metacarpals,  320 
Synovial  membrane,  21 
in  joint  injuries,  205 

swelling  of,  in  acute  polyarticular  rheu- 
matism, 207 
thickening  of,  in  villous  arthritis,  223 
Syringomyelia,  232,  302 
neuropathic  origin,  232 
A-ray    appearance     resembles     Charcot 

joint,  232,  302 
in  the  spine,  304,  305 

Tendo  Achillis,  calcification  at,  in  arthritis, 
233 

tension  of,  as  cause  of  fracture,  123 
Thoracic  vertebrae,  abnormalities  of,  314 

differential  diagnosis  concerning,  8 
Tibia,  abnormalities  of,  320 

as  site  for  giant-cell  sarcoma,  269 

centers  of  ossification  of,  40,  42 

dislocation  of,  155 

fracture  of,  113,  126 

involvement   of,   in  osteitis  deformans, 
323 
in  osteoma,  274 

-V-ray    appearance  of  Charcot  joint  in, 
230 
Tongue  and  lip,  carcinoma  of,  258 
Trapezium,  38 
Trapezoid,  38 
Trochanter,  fracture  through,  103 

greater,  39 

lesser,  40 

position  of,  in  hip  dislocation,  134 

fractures  involving  the,  107 
Trochlea,  fracture  of,  74 
Triimmer  zone   in  scurvy,    191,  195 


INDEX 


349 


Tubercle,  tibial,  injury  to,  114 
Tuberculosis,   a   factor   in   dislocation   of 
tibia,  155 
as  osteomyelitic  infection,  170 
adult  cases,  170 
children's  cases,  170 
in  infectious  arthritis,  213 
x-ray  appearance,  2 1 3 
haziness,  213 

narrowed  joint  space,  213 
atrophy,  213 
in  joint  lesions  of  children,  '83,   195 
.v-ray  appearance,  196 
hazy  and  indistinct,  196 
narrowing  of  joint  space,  196 
bone  involvement,  196 
atrophy,  presence  of,  196 
new    bone  production,  absence  of, 
197 
joint,  presence  of  atrophy  in,  211 
of  the  shaft  of  the  radius,  169 
of  the  spine,  298,  304,  305 
resemblance    of   appearance    of    hemo- 
philia to,  233 
Tuberculous  dactylitis  in  children,  171 
Tuberosity,  of  humerus,  fracture  of,  68,  71 

tibial,  fracture  of,  115 
Tumors,  as  causes  of  pressure  destruction 
in  spinal  involvement,  308 
bone,  241 

constituents    involved    in    neoplastic 

growths,  241 
analysis  of,  242 
origin,  243 

bone  production,  247 
condition  of  cortex,  247 
invasion,  251 
law  of  age,  25 1 
law  of  sex,  253 

law  of  bone  involvement,  253 
growth  of,  253 
carcinoma,  255 
cyst,  271 
hypernephroma,  2O0 


Tumors,  bone,  round-cell  sarcoma,  262 

spindle-cell  sarcoma,  263 

periosteal  sarcoma,  263 

osteosarcoma,  263 

myeloma,  266 

giant-cell  sarcoma,  267 

enchondroma  or  osteochondroma,  269 

osteoma,  272 

fibroma,  275 

myxoma,  276 

hemangioma,  276 

ossifying  hematoma,  277 

osteitis  fibrosa  cystica,  280 
brain,  282 
malignant    and    benign,    as    related    to 

fractures,  54 
of  the  spine,  302 

classification  of,  305 
Typhoid  infection  of  the  bone,  175 

Ulna,  backward  displacement  of,  76 

dislocation  of,  148 

fracture  of,  78-83 

fracture  of  styloid  of,  81 
Unciform,  38 

Vertebrae,  centers  of  ossification  of,  41 

cervical,  290 

tlioracic,  290 

lumbar,  290 

fifth,  291 

lower,   metastasis  of,   from   prostate, 
260 
rudimentary,  313 
Villous  arthritis,  223 

Wrist,  dislocation  of,  150,  151 
fractures  of,  87 

X-ray  appearance,  see  under  specific  in- 
juries and  diseases. 

Zygoma,  fracture  of,  57 


Paul  B.  Hoeber 
67-69  East  59TH  Street 

New  \'ork 


r 

rtB ; 

>8  1^7^ 

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PRINTED 

N  o.s  .                  CA 

T     NO     24    161                DW 

WE  lUl 
Blii2i 

1921 

Baetjer,  Frederick  H 

Injuries  &  diseases  of  the  bones  and 
joints. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


University  of  California 

SOUTHERN  REGIONAL  LIBRARY  FACILITY 

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CAT     NO     24    161 


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WE  lUl 

Bll+2i 

1921 
Baetjer,  Frederick  H 

Injuries  &  diseases  of  the  bones  and 
joints. 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


